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.
FAMILY MEDICAL HISTORYDo your parents or siblings have any of the following health problems? If so, please explain:
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.
MEDICAL HISTORY UPDATE OR CHANGES