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Download File - Sally Gupton, DDS
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MEDICAL HISTORY Please check yes or no if patient has or has had: Yes / No 1 Heart trouble 2 High or low blood pressure 3 Rheumatic fever 4 Mitral valve prolapse 5 Needs to pre-medicate before more extensive dental procedure 6 Diabetes 7 Thyroid problems 8 Kidney or liver problems 9 Bone disorder 10 Osteoporosis 11 Is patient taking medication for osteoporosis 12 Joint swelling 13 Arthritis 14 Rheumatoid arthritis or history of rheumatoid arthritis in your family Adolescent Females: Has menstruation begun? If yes, when (month & year) List any allergies: __________________________________________________ __________________________________________________ List medications or drugs now being taken: __________________________________________________ __________________________________________________ Yes / No 15 Emotional problems 16 Tuberculosis 17 Head trauma 18 Epilepsy or seizures 19 Faintness/dizziness 20 Anemia 21 Prolonged bleeding 22 Earaches 23 Headaches 25 Enlarged tonsils or adenoids 26 Have had tonsils or adenoids removed If yes, when 27 Can patient breath effectively through nose 28 Does patient breath through nose or mouth List any other serious illnesses: _________________________________________________ _________________________________________________ Name and address of primary care physician: _________________________________________________ _________________________________________________ Date of last visit to primary care physicians: _________________________________________________ Any change in health in the last year:__________________ __________________________________________________ DENTAL HISTORY Yes / No Does patient visit dentist regularly? Date of last visit________________________________ Name & address of D.D.S ________________________ ________________________ Has an orthodontist been consulted previously? If yes, when___________________________________ Has patient undergone previous orthodontic treatment? If yes, when Injures to face, mouth, or teeth? If yes, please describe Yes / No Missing permanent teeth Extra permanent teeth Any dental implants Any teeth replaced by bridgework Thumb or finger sucking habits Learning or speech disability Speech therapy Difficulty or pain with chewing Any pain or clicking with opening/closing Any locking of jaw (open or closed) Patients attitude towards orthodontic treatment?_________________________________________________________________ Chief complaint about teeth? What would you like to see accomplished with orthodontic treatment?_______________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________
