Dental health history

710 NW Juniper Street, Suite 202
Issaquah, WA 98027
22731 SE 29th Street
Sammamish, WA 98075

Patient Name: ___________________________________________________________________________

Check if you have had problems with any of the following:
___Any injuries to face, mouth, teeth? ___Thumb, finger, lip sucking?
___ More than average amount of decay? ___Any missing permanent teeth?
___ Any extra permanent teeth? ___ Any teeth removed by extraction?
___Any difficulty swallowing/chewing? ___Any pain or clicking when opening?
Is patient adopted? Y ( ) N ( ) What age? ____
Do you visit the dentist regularly? ____Date of last visit? ___________Any Pending dental work that needs to be completed in the next months?___________________
Has an orthodontist been consulted previously? ___ Reason____________________________
Do you or have you taken any of the following medications: ___ Actonel ___ Boniva ___ Fosamax ___ Skelid ___ Didronel
What would you like orthodontic treatment to accomplish? _______________________________________________________________________________________
Patient’s attitude toward orthodontic treatment? ___ Very motivated ___ Will cooperate if needed ___ Not motivated
Physician’s Name______________________________________________________ Phone_______________________________ Date of last visit________________
Have you had any serious illnesses or operations? ___ Yes ___ No If yes, describe_____________________________________________________________________
Have you ever taken any of the group of drugs referred to as “fen-phen?” These include combinations of lonimin, Adipex, Fastin (brand names of phentermine),
Pondimin (fenfluramine) and Redux (dexfenfluramine.) ___ Yes ___ No
Have you ever had a blood transfusion? ___ Yes ___ No If yes, give approximate Dates_________________________________________________________________
List any serious illnesses ____________________________________________________________ Is patient presently under physicians care for illness ___ Yes ___No
If yes, Reason___________________________________________
(Women) Are you pregnant? ___ Yes ___ No
Adolescent Females: Has menstruation begun __Yes __No If yes, Date: Month _____ Year _______ Approximately how much has patient grown in last year? ______
Check if you have or have had any of the following:
___ Anemia
___ Diabetes ___ High Blood Pressure ___ Skin Rash ___ Fainting ___ Kidney Disease ___ Shortness of Breath ___ Glaucoma ___ Liver Disease ___ Stroke ___ Heart Murmur ___ Mitral Valve Prolapse ___ Thyroid Problems ___ Heart Problems ___ Pacemaker ___ Tobacco Habit ___ Hepatitis ___ Radiation Treatment ___ Tonsillitis ___ Hemophilia ___ Respiratory Disease ___ Tuberculosis ___ Cough, Persistent ___ HIV/AIDS ___ Rheumatic Fever
List medications you are currently taking: _____________________________________________________________ Y N _____________________________________________________________ ( ) ( ) Other – If yes please list _________________
_____________________________________________________________ _____________________________________

The above information is accurate and complete to the best of my knowledge. I will not hold my orthodontist or any member of his/her team responsible for any errors or
omissions that I may have made in the completion of this form. If there are any changes later to this history record of medical/dental status I will also inform the
Signature_____________________________________________________________ Date______________________________


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