Comprehensive Orthodontic Medical History Form

Patient Information

• Full Name: _________________________
• Date of Birth: //____
• Age: ____
• Gender: ☐ Male ☐ Female ☐ Other

Medical History

General Health

☐ Excellent ☐ Good ☐ Fair ☐ Poor

Current Medical Conditions (Check all that apply)

☐ Heart Problems ☐ High Blood Pressure ☐ Diabetes ☐ Bleeding Disorders ☐ Bone Disorders ☐ Asthma/Respiratory Issues ☐ Epilepsy ☐ Other: _________________________

Medications

• Current Medications: _________________________
• Allergies to Medications: _________________________

Dental History

Previous Orthodontic Treatment

☐ Yes ☐ No If yes, when? _________________________

Dental Concerns

☐ Clicking/Popping in Jaw ☐ Grinding/Clenching ☐ Mouth Breathing ☐ Speech Problems ☐ Thumb/Finger Sucking

Authorization

I certify that the above information is complete and accurate to the best of my knowledge.

Signature: _________________________ Date: //____

For Office Use Only

• Reviewed by: _________________________
• Date: //____
• Notes: _________________________