Medical Dental History Form
for Patients Under Age 18
Other dentists/dental specialists now being seen:
General Information
Financial Responsibility
Dental Insurance
Medical Insurance
Other physicians/health care providers being seen currently:
Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.
For the following questions, please mark yes, no, or don't know/understand (dk/u)
Medical Insurance
Now or in the past, have you had:
Yes No DK/U
Birth defects or hereditary problems?
Bone fractures or major injuries?
Any injuries to face, head, neck?
Arthritis or joint problems?
Cancer, tumor, radiation treatment or chemotherapy?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
AIDS or HIV positive?
Hepatitis, jaundice, or other liver problems?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problems?
Mental health disturbance or depression?
History of eating disorder (anorexia, bulimia)?
Frequent headaches or migraines?
High or low blood pressure?
Excessive bleeding or bruising, anemia?
Chest pain, shortness of breath, tire easily, swollen ankles?
Heart defects, heart murmur, rheumatic heart disease?
Angina, arteriosclerosis, stroke, or heart attack?
Skin disorder (other than common acne)?
Does your child eat a well-balanced diet?
Vision, hearing, or speech problems?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoid condition?
Does your child frequently breathe through your mouth?
Has your child ever taken intravenous bisphosphonates such as Zometa (zoledronic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer?
Has your child ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel (risedronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders?
Have you had allergies or reactions to any of the following?
Yes No DK/U
Local anesthetics (novocaine, lidocaine, xylocaine)
Latex (gloves, balloons)
Ibuprofen (Motrin, Advil)
Other antibiotics
Metals (jewelry, clothing snaps)
Plant pollens
Other substances
Dental History
Now or in the past, has your child had:
Yes No DK/U
Erupting teeth very early or very late?
Primary (baby) teeth removed that were not loose?
Permanent or extra (supernumerary) teeth removed?
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, infections?
Any teeth treated with root canals or pulpotomies?
Frequent canker sores or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Mouth breathing habit or snoring at night?
Frequent oral habits (sucking finger, chewing pen, etc.)?
Teeth causing irritation to lip, cheek, or gums?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Has your child been treated for "TMJ" or "TMD" problems?
Any broken or missing fillings?
Any serious trouble associated with previous dental treatment?
Have you ever been diagnosed with gum disease or pyorrhea?
Patient Health Information
List any medication, nutritional supplements, herbal medications, or non-prescription medicines, including fluoride supplements, that your child takes.
Family Medical History
Have your parents or siblings ever had any of the following health problems? If so, please explain.
Release and Waiver
I authorize the release of any information regarding my child's orthodontic treatment to my dental and/or medical insurance company.
I have read the above questions and understand them. 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. I will notify my orthodontist of any changes in my child's medical or dental health.
Medical History Updates or Changes