• MEDICAL DENTAL HISTORY FORM FOR ADULT PATIENTS

  • CONFIDENTIAL

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  • For the following questions, mark yes, no, or don’t know/understand (dk/u). The answers are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation.

    MEDICAL HISTORY

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  • WOMEN ONLY

  • FAMILY MEDICAL HISTORY

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

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  • DENTAL HISTORY

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  • 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 the history record or medical/dental status, I will so inform the practice.

  • Clear
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  • Clear
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  • MEDICAL HISTORY UPDATE OR CHANGES

  • Clear
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  • Clear
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  • MEDICAL HISTORY UPDATE OR CHANGES

  • Clear
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  • MEDICAL HISTORY UPDATE OR CHANGES

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  • MEDICAL HISTORY UPDATE OR CHANGES

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  • Should be Empty: