Patient's Name
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Child Medical History Form
What Orthodontic Concerns Do You Have About Your Child's Teeth Or Mouth?
*
Has Your Child Suffered Any Severe Accidents Involving:
Face
Teeth
Jaws
None
Does Your Child Have Allergies Related To:
*
Asthma
Hayfever
Drugs
Latex
Other
None
Please Specify
Does Your Child Have Difficulty Breathing Through His/Her Nose?
Yes
No
Does Your Child Have Any Oral Habits Such As:
Thumb Sucking
Finger Sucking
Tongue Thrusting
Other
None
Please Specify
Has your child's tonsils or adenoids been removed?
Yes
No
If So, When?
Has Your Child Undergone Any Complex Or Unusual Dental Treatment?
Yes
No
Please Explain
Is Your Child Presently In Good General Health?
Yes
No
Is Your Child Presently Under A Physician's Care For Anything That Is Other Than Routine?
Yes
No
Physician's Name
For What Reason?
Is Your Child Currently Taking Any Medication?
Yes
No
Please List.
Has Your Child Ever Been Admitted To A Hospital?
Yes
No
For What Reason?
Has Your Child Ever Experienced Any Serious Illness Such As:
Rheumatic Fever
Auto Immune Disease
Hepatitis
Vascular Disorders
Artificial Joints
Heart Valves
Heart Disease
None
Other
Please List
Has Your Child Experienced Any Clicking Of Jaw, Pain Or Difficult Chewing?
Yes
No
When?
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Adult Medical History
What Are Your Concerns With Your Smile Or Bite?*
Have You Suffered Any Severe Accidents Involving:
Face
Teeth
Jaw
None
Do You Have Allergies Related To:
*
Asthma
Drugs
Hayfever
Latex
Other
None
Please Specify
Do You Have Difficulty Breathing Through Your Nose?
Yes
No
Do You Have Or Did You Ever Have Any Oral Habits Such As
Thumb Sucking
Finger Sucking
Tongue Thrusting
Clenching / Grinding
Other
None
Please List
Have your tonsils or adenoids been removed?
Yes
No
Have You Experienced Any Complex Or Unusual Dental Treatment?
Yes
No
Please Explain.
Are You Presently In Good General Health?
Yes
No
Are You Presently Under A Physician's Care?
Yes
No
Physician's Name
For What Reason?
Are You Currently Taking Any Medication?
Yes
No
Please List.
Have You Ever Been Admitted To A Hospital?
Yes
No
For What Reason?
Have You Ever Experienced Any Serious Illness Such As:
Rheumatic Fever
Auto Immune Disease
Hepatitis
Vascular Disorders
Artificial Joints
Heart Valves
Heart Disease
None
Other
Please List.
Have You Experienced Clicking Of Jaw, Pain Or Difficult Chewing?
Yes
No
When?
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Our Office Complies With Privacy Legislation, The Regulations Of The Royal College Of Dental Surgeons Of Ontario And The Law. Please Be Assured That Every Team Member In Our Office Is Committed To Protecting Your Personal Health Information. The Above Medical History Is Correct To The Best Of My Knowledge. I Authorize My Doctor To Consult With And/Or Send Reports And/Or Dental Practitioners As It Relates To Orthodontic Treatment.
*
I Understand
Patient's Signature
*
Patient's Full Name
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Middle Name
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