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i smile orthodontics

Patient Information

Sex:

Dental/Medical History

Now or in the past, has the patient had:

Bone fractures or major injuries to the face, head, or neck?
Cancer, tumor, radiation treatment or chemotheraphy?
Endocrine or thyroid problems?
Diabetes or low blood sugar?
Kidney or liver problems?
Stomach ulcer, hyperacidity or acid reflux?
Arthritis, joint problems or osteoporosis?
AIDS, HIV positive or any STDS?
Seizures or fainting spells?
Erupting teeth very early or very late?
Eating disorder?
Frequent headaches or migraines?
Excessive bleeding, bruising or anemia?
Heart defects, heart murmur or rheumatic heart disease?
Vision, hearing, or speech problems?
Frequent ear infections, colds or throat infections?
Asthma, sinus problems or hayfever?
Tonsil or adenoid condition?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Any lost or broken fillings?
Jaw fractures, cysts or infections?
Any teeth treated with root canals or pulpotomies?
Frequent canker sore or cold sores?
Mouth breathing habit or snoring at night?
Frequent oral habits (sucking finger, chewing pen etc.)
Teeth causing irritation to lip, cheek or gum?
Tooth grinding or clenching?
Clicking or locking jaw joints?
Soreness in jaw muscles or face muscles?
Ringing in ears, difficulty in chewing or opening jaw?
Been treated for TMJ or TMD problems?
Been diagnosed with gum disease or pyorrhea?
Frequently breathe through mouth?
Chew, smoke tobacco, or have a history of substance abuse?
Taken any medications for bone disorder?

Does the patient have allergies or reactions to any of the following?

Local anesthetics (novocaine, lidiocaine, xylocaine)
Latex (gloves, balloons)
Aspirin or Ibuprofen
Penicillin/Amoxicillin
Does the patient require an atibiotic pre-medication before dental procedures?
Is the patient pregnant or currently trying to become pregnant?

I have answered the above questions accurately and to the best of my knowledge.

Thanks for submitting!

health history

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