Confidentialmedical/Dental History Form For

Date: ______

American Association of Orthodontists

CONFIDENTIALMedical/Dental History Form For

Patients Under 18 Years of Age

Patient’s Information:

Last Name: ______ First Name: ______Middle Name/Initial: ______

Prefers To Be Called: ______Birth Date: ______Age: _____Sex: Male Female

S.S.N./S.I.N.: ______Home Phone No.: ( )- Email: ______

Address: ______City: ______State/Province: ______Zip/Postal Code: ______

Attends School At: ______Grade: _____ Height: ____ ft.____in. Weight: ____ lbs

Musical Instruments Played: ______Sports/Hobbies: ______

Name(s)/Age(s) of brothers and sisters: ______Other family members treated here: ______

Custodial Parent(s) or Guardian Information: Patient Lives With? ______

Father’s Name: ______Home Phone #: (____)______Work Phone #: (____)______

Address (if different than patient’s): ______City: ______State/Province: ______Zip/Postal Code: ______

Father’s Place of Employment:______Cell Phone: (____)______Email:______

Mother’s Name:______Home Phone #: (____)______Work Phone #: (____)______

Address (if different than patient’s):______City:______State/Province:______Zip/Postal Code:______

Mother’s Place of Employment: ______Cell Phone: ( ) - ______Email: ______

Med/Dent Info:

Name of Patient’s Dentist: ______City: ______State/Province: ______

Date last seen by Dentist: ______Reason: ______

Name of Patient’s Physician: ______City: ______State/Province: ______

Date last seen by Physician: ______Reason: ______

Financial Information:

Who is Financially Responsible For This Account? Last Name: ______First Name: ______Middle Initial: _____

Address (if different from patient’s): ______City: ______State/Province: ______

Phone No. (if different from patient’s): ( _ ) - ______S.S.N./S.I.N.: ______

Insurance Coverage for Orthodontic Treatment? Yes No

Employer:______How many years? ______Birth date: ______

Primary Policy Holder’s Name: ______S.S.N./S.I.N.: ______Employed By: ______

Dental Insurance Company: ______Group No. ______

Secondary Policy Holder’s Name: ______S.S.N./S.I.N.: ______Employed By: ______

Dental Insurance Company: ______Group No. ______

Maine Care ID # ______

Who suggested that your child might need orthodontic treatment?______

Why did you select our office? ______

What is the primary concern?(What is the problem?)______

Patient Profile:

yes no ??? Does patient follow directions well?

yes no??? Does patient brush his/her teeth conscientiously?

yes no??? Does patient have learning disabilities or needextra help with instructions?

Medical History:

Date of last physical ______yes no Does the patient need to be pre-medicated?

Now or in the past, has the patient had?

yes no ??? Birth defects or hereditary problems?yes no ??? Loss of weight recently, poor appetite?

yes no??? Mental health disturbance or behavioral problem?yes no??? History of eating disorder (anorexia, bulimia)?

yes no??? Rheumatoid or arthritic conditions?yes no ??? Endocrine or thyroid problems?

yes no??? Kidney or liver (hepatitis or jaundice) problems?yes no??? Excessive bleeding or bruising tendency, anemia or

yes no??? Diabetes? bleeding disorder?

yes no??? Stomach ulcer or hyperacidity?yes no??? Problems with tiring easily?

yes no??? Polio, mononucleosis, tuberculosis, or pneumonia?yes no??? Cancer, tumor, radiation, or chemotherapy?

yes no ??? Problems with the immune system?yes no??? Skin disorder?

yes no??? AIDS or HIV positive?yes no??? Difficulty eating a well-balanced diet?

yes no??? Chest pain, shortness of breath, or swelling ankles?yes no ??? High or low blood pressure?

yes no ??? Hay fever, asthma, sinus trouble, or hives?yes no ??? Frequent headaches, colds, or sore throats?

yes no ??? Fainting spells, seizures, epilepsy, or neuro problem?yes no??? Eye, ear, nose, or throat condition?

yes no??? Vision, hearing, tasting, or speech difficulties?yes no??? Tonsil or adenoid conditions?

yes no ??? Heart defects, stroke,murmur, or rheumatic fever?yes no ??? For girls: now or previously pregnant?

yes no ??? Substance abuse, chew or smoke tobacco? (please circle)

Are there Allergies or reactions to any of the following?

yes no ??? Local anesthetics (Novocain or Lidocaine)yes no ??? Vinyl

yes no ??? Aspirinyes no ??? Acrylic

yes no ??? Ibuprofen (Motrin, Advil)yes no ??? Animals

yes no ??? Penicillin or other antibioticsyes no ??? Foods (specify) ______

yes no ??? Sulfa drugsyes no ??? Other substances (specify) ______

yes no ??? Codeine or other narcoticsyes no ??? Is patient taking medication, nutrient supplements,

yes no ??? Metals (nickel, jewelry, clothing snaps) herbal medicines or non prescription drugs? Name:

yes no ??? Latex (gloves, balloons)Medication ______Taken for ______

Medication ______Taken for ______

Family Medical History:

Do the patient’s parents or siblings have any of the following health problems? If so, please explain:

Bleeding Disorders Diabetes Arthritis Metabolic disturbancesSevere Allergies

Unusual Dental Problems Jaw size imbalance Other family medical conditions

Describe: ______

Dental History:

Now or in the past, has the patient had?

yes no ??? Started teething very early or late?yes no ??? Pain in jaw, jaw clenching or locking?

yes no ??? Primary (baby) teeth removed that were not loose?yes no??? Pain or soreness in facial muscles or around ears?

yes no??? Supernumerary (extra) or congenitally missing teeth?yes no??? Difficulty encountered in chewing or jaw opening?

yes no ??? Chipped or injured primary(baby) or permanent teeth?yes no ??? Tooth grinding?

yes no ??? Teeth sensitive to hot or cold; teeth throb or ache?yes no??? Aware of any loose, broken, or missing fillings?

yes no??? Jaw fractures, cysts, or mouth infections?yes no??? Spaced, crooked, or protruding teeth?

yes no ??? “Dead teeth” or root canals treated?yes no ??? “Gum boils”, frequent canker sores or cold sores?

yes no ??? Bleeding gums, bad taste or mouth odor?yes no??? Taking any forms of fluoride?

yes no??? Periodontal “gum problems” or treatment?yes no??? Concern of under or overdeveloped jaw?

yes no ??? Food impaction between teeth?yes no ??? Any relative with similar tooth or jaw relationships?

yes no ??? Thumb, finger, or sucking habit? Until age ______.yes no??? Any trouble with previous dental treatment?

yes no??? Abnormal swallowing habit (tongue thrusting)?yes no??? Prior orthodontic exam or treatment?

yes no ??? History of speech problems?yes no ??? Would patient object to wearing orthodontic

yes no ??? Mouth breathing or snoring? appliances (braces) should they be indicated?

How often does your child brush? ______Floss? ______

I have read and understand the above questions. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status, I will inform this practice.

I consent to the taking of photographs and x-rays before, during, and after treatment, and to the use of them by the Doctor in scientific papers, demonstrations, or display on our website.

Signed: ______Date Signed: ______

(Parent or Guardian)

Signed: ______Date Signed: ______

(Orthodontic Staff Member)