Patient's Name
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First Name
Last Name
Patient's Birthdate:
Patient's Phone
*
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Are you in good health?
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Do you have any history of major illness? If yes please explain below:
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If you answered yes to having a history of major illness above, please explain below:
Have you ever been under the care of a physician for illness?
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Have you ever been hospitalized? If yes please explain below
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if you answered yes to having been hospitalized, please explain below:
Do you bruise easily?
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Have you ever needed a blood transfusion:
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Do you have a tendency for colds?
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Do you have a tendency for sore throats?
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Have you had your tonsils removed?
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Do you have chronic ear pain or infections?
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Do you take sedatives, tranquilizers, sleeping pills or medicine to relax?
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Do you have trouble sleeping?
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If you are female are you pregnant?
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Are you taking birth control pills?
Please list any drugs or medications you are currently taking:
Heart murmer
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Rheumatic Fever
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High blood pressure
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Low blood pressure
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Hepatitis
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Diabetes
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Kidney disease
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Epilepsy
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Fainting
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Arthritis
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Asthma
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Pneumonia
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Nervous or anxious
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Cancer treatment
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Tumors or growths
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Thyroid/parathyroid problems
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Bone disorders
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Seizures
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Endocrine problems
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Frequent headaches
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Immune system problems
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Psychiatric care
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Prolonged bleeding
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Anemia/blood pressure
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Tuberculosis
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Often fatigued/exhausted
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Recent weight gain/loss
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Sinus trouble
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Please describe any other health issues either past or present below:
Local anesthetics
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Penicillin/ other antiobiotics
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Sulfa drugs
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Barbiturates, sedatives or sleeping pills
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Aspirin
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Iodine
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Codeine or other narcotics
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Nickel
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Latex
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Do you have any other allergies or have you had negative reactions to any other drugs or substances?
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Do you have any pending dental treatment to complete? Please describe:
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Have you had any problems associated with previous dental or orthodontic treatment? Please explain:
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Have you ever had periodontal (gum) disease? If yes please describe the treatment either previous or ongoing:
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Have you been informed of any missing or extra teeth?
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Have there been any injuries/trauma to your face, mouth, or teeth? Please explain:
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Have you had any treatment for problems with your jaw joint (TMJ) or for facial muscle spasms? Please explain:
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Have you ever sucked on your thumb or fingers or had prolonged use of a pacifier as a child? At what age did you stop?
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Do you have any clicking, popping or grating of your jaw (TMJ)? If yes do you experience pain or tenderness? Please explain the severity/frequency of your symptoms:
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Is there numbness/tingling of your face or mouth?
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Do you have any speech problems?
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Have you ever had orthodontic treatment for a bad bite?
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Are you a mouth breather?
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If you do breath through your mouth, please describe at what times you tend to breath through your mouth:
Do you wear a mouthguard, nightguard or splint? If yes, was this device made by a dentist or purchased over the counter? Please also describe how long you have used it for, and how frequently you wear this device:
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Do you clench or grind your teeth? If yes would you describe it as mild, moderate, or severe?
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By writing your name below you are signing to attest that the above is correct and is only intended for use in the office of Dr. Jesse Ko & Dr. Anne Yoon at Tri-Valley Orthodontics:
First Name
Last Name
Today's Date:
MM
DD
YYYY
