Please complete the medical & dental history form below and click submit at the bottom of the page once done. If you prefer to fill out a paper copy of this form and fax or email it to us (to info@tri-ortho.com), you can find a PDF format on our Patient Forms page.

Parent/Guardian's Name *

First Name

Last Name

Patient's Name *

First Name

Last Name

Patient's birthdate: *

YYYY

Patient's Phone *

(###)

###

####

Please answer Yes or No:

Is the patient in good health? *

Yes

Does the patient have any history of major illness? If yes please explain below: *

Yes

If you answered yes to having a history of major illness above, please explain below:

Has the patient ever been under the care of a physician for illness? *

Yes

Has the patient ever been hospitalized? If yes please explain below *

Yes

if you answered yes to having been hospitalized, please explain below:

Does the patient bruise easily? *

Yes

Has the patient ever needed a blood transfusion: *

Yes

Does the patient have a tendency for colds? *

Yes

Does the patient have a tendency for sore throats? *

Yes

Has the patient had his/her tonsils removed? *

Yes

Does the patient have chronic ear pain or infections? *

Yes

Does the patient have trouble sleeping? *

Yes

Please list any drugs or medications the patient is currently taking:

Please indicate Yes or No for any conditions below the patient has experienced in the past or is currently experiencing:

Heart murmer *

Yes

Rheumatic Fever *

Yes

High blood pressure *

Yes

Low blood pressure *

Yes

Hepatitis *

Yes

Diabetes *

Yes

Kidney disease *

Yes

Epilepsy *

Yes

Fainting *

Yes

Arthritis *

Yes

Asthma *

Yes

Pneumonia *

Yes

Nervous or anxious *

Yes

Cancer treatment *

Yes

Tumors or growths *

Yes

Thyroid/parathyroid problems *

Yes

Bone disorders *

Yes

Seizures *

Yes

Endocrine problems *

Yes

Frequent headaches *

Yes

Immune system problems *

Yes

Psychiatric care *

Yes

Prolonged bleeding *

Yes

Anemia/blood pressure *

Yes

Tuberculosis *

Yes

Often fatigued/exhausted *

Yes

Recent weight gain/loss *

Yes

Sinus trouble *

Yes

Please describe any other health issues either past or present below:

Is the patient allergic or has the patient reacted adversely to:

Local anesthetics *

Yes

Penicillin/ other antiobiotics *

Yes

Sulfa drugs *

Yes

Barbiturates, sedatives or sleeping pills *

Yes

Aspirin *

Yes

Iodine *

Yes

Codeine or other narcotics *

Yes

Nickel *

Yes

Latex *

Yes

Does the patient have any other allergies or has the patient had negative reactions to any other drugs or substances? *

DENTAL HISTORY

Does the patient have any pending dental treatment to complete? Please describe: *

Has the patient had any problems associated with previous dental or orthodontic treatment? Please explain: *

Has the patient had periodontal (gum) disease? If yes please describe the treatment either previous or ongoing: *

Has the patient been informed of any missing or extra teeth? *

Yes

Has the patient had any injuries/trauma to his/her face, mouth, or teeth? Please explain: *

Has the patient had any treatment for problems with his/her jaw joint (TMJ) or for facial muscle spasms? Please explain: *

Has the patient ever sucked on his/her thumb or fingers or had prolonged use of a pacifier as a child? At what age did he/she stop? *

Has the patient had or currently have any clicking, popping or grating of his/her jaw (TMJ)? If yes does the patient experience pain or tenderness? Please explain the severity/frequency of his/her symptoms: *

Is there numbness/tingling of the patient's face or mouth? *

Yes

Does the patient have any speech problems? *

Yes

Has the patient ever had orthodontic treatment for a bad bite? *

Yes

Is the patient a mouth breather? *

Yes

If the patient breaths through his/her mouth, please describe at what times he/she tends to breath through his/her mouth:

Does the patient 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 he/she has used it for, and how frequently he/she wears this device: *

Does the patient clench or grind his/her teeth? If yes would you describe it as mild, moderate, or severe? *

Pediatric Sleep Related Breathing (SRB) Questionnaire

Pediatric airway health is crucial for our children's growth & development. Sleep Related Breathing Disorders (SRBD) are disorders characterized by disruptions in breathing patterns. Please answer the below to the best of your knowledge:

While sleeping does your child snore more than half the time? *

Yes

Not Sure

While sleeping does your child snore loudly? *

Yes

Not Sure

While sleeping does your child have "heavy" or "loud" breathing? *

Yes

Not Sure

While sleeping does your child have trouble breathing or struggle to breath? *

Yes

Not Sure

Have you ever seen your child stop breathing at night? *

Yes

Not Sure

Does your child wake up feeling unrefreshed in the morning? *

Yes

Not Sure

Does your child have problems with sleepiness during the day? *

Yes

Not Sure

Does your child occasionally wet the bed? *

Yes

Not Sure

Did your child stop growing at a normal rate at any time since birth? *

Yes

Not Sure

Is your child overweight? *

Yes

Not Sure

This child does not seem to listen when spoken to directly *

Yes

Not Sure

This child has difficulty organizing tasks and activities *

Yes

Not Sure

This child is easily distracted by extraneous stimuli *

Yes

Not Sure

This child fidgets with hands or feet or squirms in his/her seat *

Yes

Not Sure

This child is "on the go" or often acts as if "driven by motor" *

Yes

Not Sure

This child interrupts or often intrudes on others (in conversation or games) *

Yes

Not Sure

Please print your full name below to certify that the above is true to the best of you knowledge:

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:

YYYY

Thank you for submitting the medical & dental history form - finally, please complete the HIPAA form if not already done.