Kenneth S. Carlough D.M.D., M.D.S.
Jeffrey E. Burzin D.D.S.
Laura J. Gagnon D.M.D.
Christopher A. Murphy D.M.D., M.D.S.
Date:_________________
Patient’s Name_________________________________ Date of Birth_______ M____ F_____
Name of Physician_______________________________
Name of General Dentist__________________________ Date of Last Visit _______________
Medical History
Please circle yes or no to the following questions. The answers are for office records only and will be considered confidential. A complete history is
vital to a proper orthodontic evaluation.
Is the patient taking any medication?
Is there a history of major illness?
Any allergies to medication or food?
Birth defects or hereditary problems?
Are there any emotional problems?
Vision, hearing, or speech problems?
Has patient ever been hospitalized?
Does patient have a heart murmur?
Does patient smoke?
Is there a history of Rheumatic Fever?
Frequent ear or throat infections?
Is the patient adopted?
Has patient ever taken medication for
Osteoporosis?
Is the patient allergic to Nickel?
Does patient take antibiotics before
dental treatment?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
Yes
No
If yes, describe _______________________
If yes, describe _______________________
If yes, list ___________________________
If yes, describe _______________________
If yes, describe _______________________
If yes, describe _______________________
If yes, why and when __________________
____________________________________
Does the patient have allergies or reactions to any of the following:
Latex
Ibuprofen
Other Antibiotics
Acrylics
Yes
Yes
Yes
Yes
No
No
No
No
Aspirin
Penicillin
Metals
Foods
Yes
Yes
Yes
Yes
No
No
No
No
If yes, list __________
If yes, list __________
Has the patient had an illness or treatment related to any of the following:
Heart Trouble
Prolonged Bleeding
Kidney Trouble
Anemia
Liver Disease
Arthritis
Diabetes
Cancer
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Blood Pressure
Epilepsy or Seizures
Thyroid
Asthma
Hepatitis
Neurological Disorder
Fainting
AIDS or HIV Positive
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Female Patients:
Are you pregnant or do you anticipate becoming pregnant in the near future?
Yes
No
*Please turn over and fill out other side*
Dental History
Has the patient ever sucked their thumb or fingers?
If yes, until what age?____________________
Yes
No
Have there been any severe injuries to the face or jaws?
If yes, describe__________________________
_____________________________________________
Yes
No
Does the patient have jaw or TMJ problems?
If yes, describe _________________________
____________________________________________
Yes
No
Unusual dental problems?
Yes
No
If yes, describe _________________________
Does the patient grind their teeth at night or during the day?
Yes
No
Has the patient ever been told that they have periodontal or gum disease?
Yes
No
History of speech problems?
Yes
No
Does patient frequently breathe through their mouth?
Yes
No
Has patient had any previous orthodontic treatment?
Yes
No
What is the reason for this visit? _______________________________________________
NOTES: _________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
I authorize Child and Adult Orthodontics to take the necessary X-rays before, during and after my child’s
orthodontic treatment. Initials________
Signature of Patient, Parent or Guardian______________________________ Date ___________
Updated History
Date
Initials
__________
_________
__________
_________
__________
_________
__________
_________
__________
_________
__________
_________