For the following questions, mark Y (Yes), N (No) or U (Unknown). The answers are for office records only and will be considered confidential. A thorough and complete history is vital to a proper orthodontic evaluation. |
Medical History |
Birth defects or hereditary problems? Y N U
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Rheumatoid or arthritic conditions? Y N U
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Bone fractures, any minor accidents? Y N U
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Cancer, tumor, radiation treatment or chemotherapy? Y N U
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Polio, mononucleosis, tuberculosis, pneumonia? Y N U
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Problems of the immune system? Y N U
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Does patient wear an artificial prothesis? Y N U
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Eye, ear, nose or throat condition? Y N U
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Hayfever, asthma, sinus trouble or hives? Y N U
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Loss of weight recently, poor appetite? Y N U
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Vision, hearing, tasting or speech difficulties? Y N U
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Fainting spells, seizures, epilepsy or neurological problem? Y N U
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Chest pain, shortness of breath or swelling ankles? Y N U
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Kidney Problems? Y N U
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Endocrine or thyroid problems? Y N U
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Diabetes? Y N U
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Stomach ulcer or hyperacidity? Y N U
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Tonsil or adenoid conditions? Y N U
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AIDS or HIV positive? Y N U
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High or low blood pressure? Y N U
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Tired easily? Y N U
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Skin disorder? Y N U
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Osteoporosis? Y N U
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History of eating disorder? Y N U
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Hepatitis, jaundice or liver problem? Y N U
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Mental health disturbance or depression? Y N U
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Frequent headaches, colds or sore throats? Y N U
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Does patient have a well-balanced diet? Y N U
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Allergy History |
Local anesthetics (Novocaine etc.) Y N U
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Aspirin Y N U
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Ibuprofen (Mortin, Advil) Y N U
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Penicillin or antibiotics Y N U
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Sulfa drugs Y N U
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Codeine or narcotics? Y N U
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Metals (jewelry, buttons) Y N U
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Latex (gloves, balloons) Y N U
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Vinyl Y N U
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Acrylic Y N U
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Animals Y N U
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Tobacco user? Y N U
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Foods Y N U
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Other substances Y N U
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Specify
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Specify
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Is patient taking medication, nutrient supplements, herbal medications or non prescription medicine? Please name them. Y N U
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Medicine Taken For
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Medicine Taken For
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