American Association of Orthodontists
Patient's Last Name: ___________________________ First Name: _____________________________ I Prefer To Be Called: _______________________ S.S.N./S.I.N.: _______________ Home Phone No.: ( E-mail address: ___________________________________________ Cell phone number: ____________________ Pager number:____________________ Patient's Address: _____________________________________________________________________________ If less than 5 years at current address, previous address:___________________________________________________________________________________ Employer:________________________________ Name Of Spouse/Closest Relative: ________________________________ Relationship To You: __________________________ Address (if different than yours): _____________________________________________________________________________ Name Of Patient's Dentist: ___________________________________ Dentist's Address: ____________________________________________________________________________________ Reason: _________________________________________________ Name Of Patient's Physician(s): _________________________________________ Physician's Address: _______________________________________________________________________ Reason: __________________________________________ Who suggested that you might need orthodontic treatment? _____________________________ Why did you select our office? ____________________________________________________ Who Is Financially Responsible For This Account? Last Name: ________________________________ Address (if different than patient’s)______________________________________________________________________ City: ______________________________________ Insurance Coverage For Dental Treatment? Yes Insurance Coverage For Orthodontic Treatment? Yes Primary Policy Holder's Name: _____________________________________________-_______________ Employed By: __________________________________________________________ Dental Insurance Company: _________________________________________________________ Secondary Policy Holder's Name: __________________________________________ S.S.N./S.I.N.: _______________________________ Employed By: __________________________________________________________ Dental Insurance Company: _____________________________________________ Medical Insurance Company: ______________________________ or 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.
Now or in the past, have you had:
dk/u Are you currently taking or have you ever taken any
intravenous bisphosphonates for serious bone dk/u Birth defects or hereditary problems?
disorders/cancers: such as Zometa (zolendronic acid), Aredia dk/u Bone fractures, any major accidents?
dk/u Rheumatoid or arthritic conditions?
dk/u Are you currently taking or have you ever taken any oral
dk/u Endocrine or thyroid problems?
bisphosphonates for osteoporosis, osteopenia or other uses: such as Fosamax (alendronate), Actonel (risendronate), dk/u Kidney problems?
Boniva (ibandronate) Skelid (tiludronate), Didronel dk/u Diabetes?
dk/u Cancer, tumor, radiation treatment or chemotherapy?
dk/u Are you taking medication, nutrient supplements, herbal
dk/u Stomach ulcer or hyperacidity?
medications or non prescription medicine? Please name them. dk/u Polio, mononucleosis, tuberculosis, pneumonia?
dk/u Problems of the immune system?
dk/u AIDS or HIV positive?
dk/u Hepatitis, jaundice or liver problem?
dk/u Fainting spells, seizures, epilepsy or neurological problem?
dk/u Mental health disturbance or depression?
dk/u Vision, hearing, tasting or speech difficulties?
dk/u Loss of weight recently, poor appetite?
dk/u History of eating disorder (anorexia, bulimia)?
dk/u Excessive bleeding or bruising tendency, anemia or
dk/u Do you currently have or ever had a substance abuse
dk/u High or low blood pressure?
dk/u Do you chew or smoke tobacco?
dk/ u Tired easily?
dk/u Operations? Describe: _______________________
dk/u Chest pain, shortness of breath or swelling ankles?
dk/u Hospitalized? For: __________________________
dk/u Cardiovascular problem (heart trouble, heart attack, angina,
dk/u Other physical problems or symptoms? Describe: _______
coronary insufficiency, arteriosclerosis, stroke, inborn heart defects, heart murmur or rheumatic heart disease)? dk/ u Being treated by another health care professional?
dk/u Skin disorder?
Date of most recent physical exam? __________________ dk/u Do you have a well-balanced diet?

Do you have any other medical conditions that we should know about?
dk/u Frequent headaches, colds or sore throats?
________________________________________________________ dk/u Eye, ear, nose or throat condition?
dk/u Hayfever, asthma, sinus trouble or hives?
dk/u Tonsil or adenoid conditions?
dk/u Osteoporosis?
dk/u Are you pregnant?
dk/u Are you anticipating becoming pregnant?
Allergies or reactions to any of the following:
dk/u Local anesthetics (Novocaine or Lidocaine)
dk/u Aspirin
Do your parents or siblings have, or have ever had any of the following dk/u Ibuprofen (Motrin, Advil)
dk/u Penicillin or other antibiotics
Bleeding disorders________________________________________________ dk/u Sulfa drugs
Diabetes________________________________________________________ dk/u Codeine or other narcotics
Arthritis________________________________________________________ dk/u Metals (jewelry, clothing snaps)
Severe allergies__________________________________________________ dk/u Latex (gloves, balloons)
Unusual dental problems___________________________________________ dk/u Vinyl
Jaw size imbalance________________________________________________ dk/u Acrylic
Any other family medical conditions that we should know about? ___________ dk/u Animals
dk/u Foods (specify) ___________________________________
dk/u Other substances (specify) __________________________
dk/u Any pain or soreness in the muscles of the face or around
Now or in the past, has the patient had:
dk/u Permanent or "extra" (supernumerary) teeth removed?
dk/u Difficulty in chewing or jaw opening?
dk/u Supernumerary (extra) or congenitally missing teeth?
dk/u Have you ever been treated for "TMD" or "TMJ" problems?
dk/u Chipped or otherwise injured primary (baby) or permanent
dk/u Aware of loose, broken or missing restorations (fillings)?
dk/u Any teeth irritating cheek, lip, tongue or palate?
dk/u Teeth sensitive to hot or cold; teeth throb or ache?
dk/u Concerned about spaced, crooked or protruding teeth?
dk/u Jaw fractures, cysts or mouth infections?
dk/u Aware or concerned about under or over developed jaw?
dk/u "Dead teeth" or root canals treated?
dk/u Any relative with similar tooth or jaw relationships?
dk/u Bleeding gums, bad taste or mouth odor?
dk/u Any wisdom tooth problems?
dk/u Periodontal "gum problems"?
dk/u Had periodontal (gum) treatment?
dk/u Food impaction between teeth?
dk/u Had any serious trouble associated with any previous dental
dk/u "Gum boils", frequent canker sores or cold sores?
dk/u Thumb, finger, or sucking habit? Until what age ________?
dk/u Been under another dentist's care?
Specialist _______________________________ dk/u Abnormal swallowing habit (tongue thrusting)?
Other __________________________________ dk/u History of speech problems?
dk/u Ever had a prior orthodontic examination or treatment?
dk/u Mouth breathing habit, snoring or difficulty in breathing?
dk/u Would you object to wearing orthodontic appliances
dk/u Tooth grinding or jaw clenching?
dk/u Any pain, clicking or locking in jaw or ringing in the ears?

How often do you brush:
What is your primary concern? Why are you here? __________________________________________________________________ Questions: ___________________________________________________________________________________________________________________________ DOCTOR CONTACT INFORMATION
Doctor's Last Name: _____________________________ E-mail address: ____________________________________________ Doctor's Address: _____________________________________________________________________________ City: _______________________________________ 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 this history record or medical/dental status, I will so inform this practice. Signed: ______________________________________________________ Date Signed: ________________ (Patient) Signed: ______________________________________________________ Date Signed _________________ (Dental staff member) MEDICAL HISTORY UPDATE OR CHANGES
Comments: _______________________________________________________________________________ Signed: ______________________________________________________ Date Signed: ________________ (Patient) Signed:_______________________________________________________ Date Signed: _______________ (Dental Staff Member) MEDICAL HISTORY UPDATE OR CHANGES
Comments: ______________________________________________________________________________

Signed: ______________________________________________________ Date Signed: ________________
Signed:_______________________________________________________ Date Signed: _______________
(Dental Staff Member)
Comments: ______________________________________________________________________________

Signed: ______________________________________________________ Date Signed: ________________
Signed:_______________________________________________________ Date Signed: _______________
(Dental Staff Member)
Comments: _______________________________________________________________________________
Signed: ______________________________________________________ Date Signed: ________________
Signed:_______________________________________________________ Date Signed: _______________
(Dental Staff Member)
American Association of Orthodontists 2003


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