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ORTHODONTIC CONSULTATION

ORTHODONTIC CONSULTATION:

ORTHODONTIC CONSULTATION:

PATIENT INFORMATION

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MEDICAL INFORMATION

Heart Disease(Required)
Infective Endocarditis(Required)
Heart Defect / Repair(Required)
Cancer(Required)
Diabetes(Required)
Blood Disease(Required)
Sleep Apnea(Required)
Asthma(Required)
Arthritis(Required)
Tuberculosis(Required)
Hepatitis A, B or C(Required)
H.I.V / A.I.D.S(Required)
Liver Disease(Required)
Prolonged Bleeding(Required)
Autism(Required)
Other medical conditions (not listed above)
Is antibiotic medication required for dental cleanings?(Required)
Have tonsils and/or adenoids been removed?(Required)
(Women) Are you pregnant?
Have you ever taken medications for osteoporosis?(Required)

DENTAL INFORMATION

Have you ever seen a Periodontist (gum specialist)?(Required)
Have there been any injuries to the face, mouth or teeth?(Required)
Any thumb or finger habit?(Required)
Are you a mouth breather?(Required)
Any speech problems?(Required)
Has there been a previous orthodontic examination?(Required)
Frequent canker or cold sores?(Required)
Ever had braces or orthodontic treatment?(Required)
Have any other family members(Required)
Do gums bleed when brushing or flossing?(Required)
Has there ever been treatment for a jaw joint problem, including surgery?(Required)
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