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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Garner Orthodontics Medical and Dental History Patient Name: _________________________________________ Date: _________________________ Dentist’s Name: ______________________________ Date of last exam/cleaning: ________________ PLEASE MARK THE ITEM/ITEMS YOU HAVE A HISTORY OF: □ Birth Problems □ Lupus □ Speech Problems □ Learning Disabilities □ Tonsils/Adenoid Problems □ Attention Deficit Disorder □ Diabetes □ Arthritis □ Cancer □ Bleeding or Hemophilia □ Blood Transfusion □ Hepatitis □ AIDS or HIV+ □ Tuberculosis □ Venereal Disease □ High Blood Pressure □ Asthma □ Sleep Apnea □ Osteoporosis □ Mononucleosis □ Heart Murmur □ Chronic Cough □ Thyroid Condition □ Hearing Loss □ Growth Problems □ Rheumatic Fever □ Anemia □ Cerebral Palsy □ Vision Problems □ Radiation or Chemotherapy □ Smoking □ Smokeless Tobacco □ Drug or Alcohol Use □ Hypoglycemia □ Epilepsy or Seizures □ Cleft Lip or Cleft Palate □ Liver Disease □ Kidney Disease □ Emotional or Behavior Problems □ Skin Problems □ Psychotherapy □ Fainting PLEASE MARK ALL THAT APPLY AND PROVIDE AN EXPLANATION: □ Allergies to Latex, Metal or Medications: _________________________________________________ □ Frequent Headaches: _________________________________________________________________ □ Surgery: ___________________________________________________________________________ □ Jaw popping, clicking or locking: ________________________________________________________ □ Under care of dentist, physician or chiropractor: ___________________________________________ □ Pain in face, jaw or back: ______________________________________________________________ □ Car accident: ________________________________________________________________________ □ Grinding or clenching teeth: ____________________________________________________________ □ Head, neck or face injury: ______________________________________________________________ □ Premedication required for dental work: __________________________________________________ LIST ALL MEDICATIONS YOU ARE TAKING, INCLUDING NAME AND REASON FOR USE: _____________________________________________________________________________________ _____________________________________________________________________________________ I certify that the above information is correct. SIGNATURE: ____________________________________ Printed Name: __________________________________ SIGNATURE OF DOCTOR: __________________________ DATE: ______________________________ Relationship to patient: ________________ DATE: _______________________________