Full Health History Form | Du Raan Orthodontics

Patient Biographical Information

Financial Party Information

Check if the patient is also the person who will be financially responsible for treatment.

If less than 3 years, please provide us with the details of your previous address *

Dental Insurance Information

Emergency Information

Dental History

Has the patient had an orthodontic consultation or treatment?

Yes

Does the patient need to premedicate prior to dental visit?

Yes

Please select YES if the patient has had any of the conditions listed below either now or in the past.

Speech problems/therapy

Yes

Clench or Grind Teeth

Yes

Oral habits (thumb/finger sucking, lip/nail biting)

Yes

Injury to face, jaw, teeth or mouth

Yes

Discomfort from teeth or gums

Yes

Pain, tenderness or noise in either jaw

Yes

Frequent headaches

Yes

Neck / Shoulder Pain

Yes

Frequent sore throats

Yes

Chipped or injured permanent teeth

Yes

Teeth sensitive to hot or cold

Yes

Previous root canal therapy

Yes

Bad taste / mouth odor

Yes

Previous periodontal (gum) treatment

Yes

Abnormal swallowing (tongue thrust)

Yes

Teeth that irritate tongue, cheek, lip, etc.

Yes

Numerous fillings

Yes

Brush teeth daily

Yes

Floss teeth daily

Yes

Fluoride treatments

Yes

Mouth breathing

Yes

Snores during sleep

Yes

Any missing or extra permanent teeth

Yes

Apprehensive about dental care

Yes

Frequently Chew Gum

Yes

Thumb or finger habit as a child

Yes

Jaw fractures, cysts, mouth infections

Yes

Bleeding gums

Yes

Other periodontal (gum) problems

Yes

Frequent canker sores or cold sores

Yes

Have wisdom teeth been removed?

Yes

Problems with food trapped between teeth

Yes

Is all dental work completed?

Yes

If any of the above dental questions were answered 'Yes', please explain:

Have you had a TMJ screening?

Yes

Do you have a history of jaw joint problems

Yes

Have you been treated for TMJ?

Yes

Do you notice clicking or popping in your jaw joint?

Yes

Do you clench your teeth?

Yes

Has your jaw ever locked?

Yes

Do you have difficulty chewing or opening your mouth?

Yes

Does your bite feel uncomfortable or unusual

Yes

Do you experience soreness in the muscles of your face or around your ears?

Yes

If any of the above TMJ questions were answered 'Yes' please explain:

Medical History

Patient Health conditions

Has there been any change in the patient's general health within the last year?

Yes

Is the patient now under the care of a physician (other than routine)?

Yes

If so, what is being treated?

Has the patient had a serious illness/hospitalisation in the past 5 years? *

Yes

If so, what for?

List any medications currently being taken by the patient (include non-prescription):

Allergies or drug reaction to:

Latex *

Yes

Penicillin or other antibiotics *

Yes

Sulfa drugs *

Yes

Aspirin, Ibuprofen, Tylenol *

Yes

Local anesthetics *

Yes

Codeine or other narcotics *

Yes

Latex / Metal Allergy *

Yes

Other *

Yes

List any drug allergies or sensitivities (not listed above) that the patient may have:

Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.

Heart Murmur *

Yes

Damaged or artificial heart valves *

Yes

Congenital Heart Defect *

Yes

Heart Disease *

Yes

Rheumatic Fever *

Yes

Angina *

Yes

Liver Disease / Jaundice / Hepatitis *

Yes

Kidney Disease *

Yes

Heart Attack / Stroke *

Yes

Hemophilia *

Yes

Hypertension / High Blood Pressure *

Yes

Prolonged Bleeding / Transfusion *

Yes

Anemia / Blood Disorder *

Yes

HIV / AIDS *

Yes

Tonsils / Adenoids Removed *

Yes

Handicaps / Disabilities *

Yes

Arthritis / Joint problems *

Yes

Large Tonsils *

Yes

Sinus_Trouble *

Yes

Bed_Wetting *

Yes

Substance abuse problems (past or present) *

Yes

Bone fractures / Trauma to face / Jaw *

Yes

Prosthetic Joints *

Yes

Chronic Fatigue *

Yes

Diabetes *

Yes

Diabetes *

Yes

Growth Problems *

Yes

Tuberculosis or Lung Disease *

Yes

Pneumonia *

Yes

Cancer *

Yes

Family History of Cancer *

Yes

Received Radiation Treatment *

Yes

Arteriosclerosis *

Yes

Thyroid / Endocrine Problems *

Yes

Stomach Ulcer or Hyperacidity *

Yes

Hormone Therapy *

Yes

Nervous Disorders *

Yes

Bone Disorders/Bone Loss *

Yes

Seizures / Epilepsy / Neurological Disease *

Yes

Treated for Emotional Problems *

Yes

Asthma *

Yes

Respiratory Problems / Emphysema *

Yes

Persistent swollen neck glands *

Yes

Sexually Transmitted Disease *

Yes

Low Blood Pressure *

Yes

Persistent Cough *

Yes

FEMALES: Are you pregnant? *

Yes

Take Bisphosphonates (Fosamax, Boniva) *

Yes

If any of the above medical questions were answered 'Yes' , please explain: *

Yes

Patient Motivation for Orthodontic Treatment

Patients often request changes in their bites or faces and relief from pain or discomfort.

Please help us to understand your concerns by checking the following information; please be specific (check the words - upper, lower, more, etc.)

Teeth - If your teeth could be changed, how would you like them to change?

Straighten Front Teeth

Upper

Lower

Both

Straighten Back Teeth

Upper

Lower

Both

Move Upper Teeth

Forward

Backward

Move Lower Teeth

Forward

Backward

Eliminate Spaces Between Teeth

Upper

Lower

Both

Eliminate Crowding of Teeth

Upper

Lower

Both

Make Line of Upper Teeth More Level

Other

Face - If your facial appearance could be changed, what would you change?

Move Upper Lip

Forward

Backward

Move Lower Lip

Forward

Backward

Show my teeth when I smile

Less

Show my gums when I smile

Less

Make my nose

Longer

Shorter

Move chin

Forward

Backward

Move chin

Left

Right

Reduce the strain when I close my lips in my:

Chin

Lips

Both

Close together

Farther apart

Close together

Father apart

Patient Motivation for Orthodontic Treatment

If patient is under the age of 18, please answer the following questions:

Has patient begun puberty:

Yes

If patient is a girl, has menstruation begun:

Yes

If patient is a boy, has their voice changed or have facial hair:

Yes

Has the patient grown in the past year or has their shoe size changed recently:

Yes

Has either biological parent ever had orthodontic treatment:

Yes

I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.

I understand that where appropriate, credit bureau reports may be obtained.

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Important COVID-19 Information

Patient Biographical Information

Financial Party Information

Dental Insurance Information

Emergency Information

Dental History

Please select YES if the patient has had any of the conditions listed below either now or in the past.

Medical History

Allergies or drug reaction to:

Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.

Patient Motivation for Orthodontic Treatment

Teeth - If your teeth could be changed, how would you like them to change?

Face - If your facial appearance could be changed, what would you change?

Patient Motivation for Orthodontic Treatment

If patient is under the age of 18, please answer the following questions: