About You – The PatientToday dateLast nameFirst nameMrMsMissMrsDrGenderMaleFemaleDate of birthday/month/yearAddressCityProvincePostal CodeHome phone numberWork phone numberExtCell phone/otherE-mailWhen and where are the best times to reach you?Whom may we thank for referring you to our office?Other family members seen by usDentistPreviousPresentDoes your insurance cover orthodontic work?YesNoEmergency ContactNameRelationPhone number where they can be reached during the dayIf MinorPerson(s) responsible for accountSecondary address (if applicable)CityProvincePostal CodeMother’s nameHome phone numberWork phone numberExtCell phone numberE-mailFather’s nameHome phone numberWork phone numberExtCell phone numberE-mailGuardian’s nameHome phone numberWork phone numberExtCell phone numberE-mailFor diagnostic reasons, has the patient reached puberty?YesNoMedical HistoryPhysician NamePhone numberYour current physical health is:GoodFairPoorIf poor, please explain :Do you smoke or use tobacco in any other form?YesNoHave you ever had any of the following diseases or medical problems?Abnormal Bleeding/ HaemophiliaYesNoAlcohol/Drug AbuseYesNoAnaemiaYesNoArthritisYesNoArtificial Bones/Joints/ValvesYesNoAsthmaYesNoBlood PressureHighLowBlood TransfusionYesNoCancer / ChemotherapyYesNoColitisYesNoCongenital Heart DefectYesNoDiabetesYesNoDifficulty BreathingYesNoEmphysemaYesNoEndocrine ProblemsYesNoEpilepsyYesNoFainting/DizzinessYesNoFrequent HeadachesYesNoGlaucomaYesNoHeart Attack/SurgeryYesNoHeart MurmurYesNoHepatitisYesNoHerpes/Fever BlistersYesNoHIV/AIDSYesNoKidney ProblemsYesNoLiver DiseaseYesNoLupusYesNoNervous DisordersYesNoPneumoniaYesNoRadiation TreatmentYesNoRheumatic FeverYesNoSeizuresYesNoShinglesYesNoSickle Cell DiseaseYesNoSinus ProblemsYesNoThyroid ProblemsYesNoTuberculosisYesNoUlcersYesNoOtherAre you currently taking any prescription drugs?YesNoIf so, please list each oneAre you or do you think you might be pregnant?YesNoPlease list any allergies that you may haveDental HistoryHave you ever been evaluated for orthodontic treatment?YesNoHave you ever experienced pain in your jaw joint? (TMJ/TMD)YesNoHave you ever had an injury to your:MouthTeethChinDo you have speech problems?YesNoDo you generally breathe through your mouth?YesNoIf so, please specify:While AwakeWhile AsleepHave you had your tonsils removed?YesNoDid you ever suck your thumb?YesNoDo you have missing/extra teeth?MissingExtraNoDo you like your smile?YesNoWhat do you want to change with orthodontic treatment?I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my medical status.By typing your name in this field you are agreeing to all conditions and terms that apply, and attesting to the accuracy of the answers given.(Parent or guardian if minor)(required)Date(required)day/month/yearOur office respects and exceeds infection control standards mandated by the Canadian Dental Association and the Canadian Association of Orthodontists.SubmitThis field should be left blank
