Patient: _____________________________ Date: ____________            MEDICAL ALERT

 

Practice Limited to Orthodontics

certified OrthoClearR orthodontist

Patient Health History

 

Patient’s Name: __________________________________________ Home Phone: (_______)_______________________

 

Address: _____________________________________________ Business Phone: (_______)_______________________

 

City: _________________________________________ State: ______________ Zip code: _________________________

 

E-mail: ____________________________

 

Date of Birth: ____________________ Sex:  M   F   Responsible Party if under 18: _______________________________

General Dentist: _________________________________      Physician: ________________________________________

 

Last visit: _______________________________________      Last Visit: ________________________________________

 

What would you like to change about your teeth/face?__________________________________________________

 

________________________________________________________________________________________________

 

How often do you brush your teeth? __________________  How often do you floss your teeth? ___________________

 

Do you ever have tooth or jaw pain? ............................................................................................................. Yes   No

 

Are you familiar with the term “preventive dentistry”?  ..........................................….................................. Yes   No

 

Are you in good health? ................................................................................................................................. Yes   No

 

Has there been any change in your health  within the past year? .................................................................  Yes  No

 

   Please explain  ______________________________________________________________________________________

 

Have you  ever been hospitalized overnight? ................................................................................................ Yes   No

 

   Please explain ______________________________________________________________________________________

 

What medicines or over-the-counter remedies do you take? ____________________________________________

 

Do you have any heart conditions? ............................................................................................................... Yes   No

 

   Please explain ______________________________________________________________________________________

 

Have you had any complications with previous dental treatment? ..............................................................  Yes  No

 

   Please explain ______________________________________________________________________________________

over please

 

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