Medical History Medical History Patient's Name Is patient in good health? YesNo Does patient have any history of illness? YesNo Please choose any of the following that the patient was treated for: DiabetesTuberculosisEndocrineProblemsProlongedBleedingPneumoniaAnemiaHeartTroubleEpilepsyDizzinessNervousDisordersBoneDisordersKidneyDisordersRheumaticFeverAsthmaNasalBlockageLiverDisorders Does patient have tendency toward: ColdsSore ThroatsEar InfectionsHeadaches Has patient ever been exposed to: HerpesAIDSHepatitis Have tonsils and/or adenoids been removed? YesNo Next Dental History Does patient want teeth straightened? YesNo Does patient have speech problems? YesNo Has patient ever sucked a thumb or a finger? YesNo Does patient breathe through the mouth while awake? YesNo or while asleep? YesNo Has patient been informed of any missing teeth? YesNo any extra teeth? YesNo Does patient have popping jaw or pain in jaw? YesNo frequent headaches? YesNo Has patient had injuries to the face or jaw? YesNo clinch or grind teeth? YesNo PreviousNext Family History Please list the children in your family and indicate if they had had orthodontic treatment. Orthodontics YesNo Orthodontics YesNo Orthodontics YesNo Orthodontics YesNo Has either parent had orthodontic treatment? YesNo Are you aware that some appointments will infringe on school time? YesNo Have you previously consulted an orthodontist? YesNo Next
