Patient Name
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Date of birth
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MM slash DD slash YYYY
Are you under medical treatment now?
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Yes
No
Has the patient been hospitalized for any surgical operations or serious illness in the past five years?
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Yes
No
Please describe the surgical operation(s) or illness(es).
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Are you taking medication(s) Including non-prescription medicine?
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Yes
No
If yes, what medication(s) are you taking?
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Do you use tobacco?
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Yes
No
Are you aware of being allergic to any medications or substance, including metals?
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Yes
No
If yes, what?
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Has the patient ever taken Bisphosphonates (EX: Fosamax) for Osteoporosis?
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Yes
No
If yes, specify
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Please check all that apply
Hay Fever/Allergies
Cold Sores
Migraines
Diabetes/Glaucoma
Rheumatic Fever
AIDS or HIV Infection
Cardiac Pacemaker
Asthma (Inhaler)
Fainting/Seizures
Thyroid Problem
High/Low Blood Pressure
Heart Trouble
Epilepsy/Convulsions
Removal of Adenoids/Tonsils
Leukemia
Kidney/Liver Disease
Anemia
Cancer
Joint Replacement/Implant
Hepatitis/Jaundice
Stomach Troubles/Ulcers
Sinus Problems
Stroke
Radiation Therapy
Respiratory Problems
Bone Disorder
Osteopemia/Osteoporosis
Females only: are you pregnant, or think you may be?
Yes
No
Are you anxious or nervous about dental treatment?
Yes
No
Do you require premedication for dental treatment?
Yes
No
Do you feel pain to any of your teeth?
Yes
No
Do you have any sores or lumps in or near your mouth?
Yes
No
Have you had any head, neck, or jaw injuries?
Yes
No
If yes, please describe
Does the patient have any ongoing problems in their jaw with:
Chronic clicking or popping?
Pain?
Difficulty opening or closing?
Difficulty in chewing?
Do you clench or grind your teeth?
Yes
No
Do you bite your lips or cheeks frequently?
Yes
No
Have you ever had speech therapy?
Yes
No
If yes, please describe
Is there any outstanding dental treatment to be completed?
Yes
No
If yes, please describe
Have you ever had instruction on the correct method of brushing and flossing your teeth?
Yes
No
Do you have any of the following oral habits:
Nail Biting?
Thumb Sucking?
Tongue Thrust While Swallowing?
Mouth Breathing?
How many times a day do you brush?
Please check the boxes below which describe the problem(s) for which the patient is seeking treatment for:
Crowding
Extra Space
Teeth Stick Out Too Far
TMJ Problems
Poor Bite Relationship
Missing Teeth
Extra Permanent Teeth
Teeth Erupting in the Wrong Position
Other
What other problem:
Has the patient had an orthodontic evaluation or treatment before?
Yes
No
If so, when and by whom?
Authorization and Release
To the best of my knowledge the above questions have been accurately answered and it is my responsibility to inform this office of any changes to the patient's medical status. I give Petrover Orthodontics permission to perform the necessary dental services that the patient may need. I hereby grant to Petrover Orthodontics the absolute and irrevocable right and permission, throughout the world, in respect of the photographs audio, and video it has taken of me or acquired of me: 1) To use, re-use, publish and re-publish and otherwise reproduce, distribute, publicly display and publicly perform the same, in whole or in part, in any and all media including practice website and social media, now or hereafter known for illustration, promotion, advertising, trade or any other purpose whatsoever; and 2) To use my name and written testimonial in connection with the material. If it so chooses, I hereby release and discharge grantee from any clams and demands arising out of or in connection with the use of the materials, including without limitation any and all claims for defamation, invasion of privacy, and misappropriation of my right of publicity.
Patient or Guardian Signature
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Email
This field is for validation purposes and should be left unchanged.