DETAILED ORTHODONTIC HISTORY FORM

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1PATIENT DETAILS

2INSURANCE

3MEDICAL HISTORY

4DENTAL HISTORY

5CONSENT

PATIENT DETAILS:

In order to provide you with high standard of orthodontic care, it is important for us to know patients
medical and dental history as this can affect the outcome of the treatment.

Name *

First

Last

Date of Birth *

Gender *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Phone *

Parents/ Guardians:

Parents/Guardians

Parents Name *

Phone *

Parents Name

Phone

Email *

Name of the person who referred you to us

INSURANCE DETAILS:

Private health fund *

Name *

Number *

Medicare *

Medicare number *

Reference Number *

MEDICAL HISTORY:

Name of your G.P *

GP's clinic name / Address

GP's Contact Number

Are you in good health? *

Please Explain *

Do you have a history of a major illness? *

Please list any illnesses *

Have you had any operations or been hospitalized? *

Please list any surgeries/hospitalizations *

Have you ever been involved in a serious accident? *

Please specify the details *

Have you ever smoked or chewed tobacco? *

Please specify how often *

Are you taking any prescription and/or over-the-counter medication?

Please list all medications *

Are you allergic to any medication or substance (including latex or metals)? *

Please list all allergies *

Have any tonsils or adenoids been removed? *

Please specify at what age and why ? *

Are you pregnant? *

Are you nursing? *

Do you have any of the following conditions ? *

Abnormal bleeding/Hemophilia
Diabetes
Heart Problems
Anemia
Developmental Disorder
Stroke
Arthritis
Dizziness
Hepatitis/Jaundice
Asthma
Endocrine Disorder
Herpes/Cold Sores
Bone Disorders
Epilepsy/Convulsions/ Seizures
High/Low Blood Pressure
Behavioral Disorder
Growth Disorder
HIV+ / Aids
Cancer
Kidney Disease
Leukemia
Congenital Heart Defect
Hay Fever/Allergies
Liver Disease
Migraines/Severe Headaches
Psychiatric Problems
Lung/Respiratory Problems
Nervous Disorders
Radiation/Chemotherapy
Thyroid Problems
Pneumonia
Rheumatic/Scarlet Fever
Tuberculosis
Prolonged Bleeding
Sinus Problems
Covid – 19
None of the above

Please select all that apply

Please explain

DENTAL HISTORY

Name of your Dentist *

Dentist's clinic name / Address

Phone

Date of the most recent dental exam/x-rays/Cleaning? *

What are the main concerns you would like the doctor to address

Have you ever had or been evaluated for Orthodontic treatment? *

Please specify the details *

Are you currently in any dental pain? *

Please specify the details *

Have you ever experienced any unfavourable reaction to dental products? *

Please list any reactions *

Have you ever lost or chipped any baby or adult teeth? *

Please specify the details *

Have you ever been informed of any missing or extra teeth? *

Please specify the details *

Have there been any injuries (even minor) to face, mouth, or teeth? *

Please specify the details *

Are your teeth sensitive to hot or cold or to biting? *

Please specify the details *

Do your gums bleed when you brush? *

Please specify the details *

Do you play any sports? *

Do you use mouth guards while playing sports? *

Are you aware of your jaw joint clicking or popping (TMJ/TMD) *

Please specify the details *

Are you aware of clenching/grinding of your teeth? *

Do your teeth or jaws ever feel uncomfortable when you awake in the morning? *

Do you have “tension” headaches? *

Please specify the details *

Did you have any type of thumb sucking or tongue licking habit? *

Do you have any speech problems? *

Please explain *

Are you a mouth breather? *

Have you ever seen an ENT with any airway or any other issues? *

Please specify the details *

Do you drink carbonated, sugary drinks or alcohol? *

Does your diet consist of sugary treats, chocolates, candies on regular basis? *

How often do you brush your teeth? *

Do you floss? *

Has anyone in your family received orthodontic treatment? *

Please provide the details *

CONSENT *

By checking the box and signing this form, I acknowledge and consent to the following:

I have truthfully answered all of the above questions and agree to inform this office of any changes in my medical or dental history.
I understand that I am responsible for attending the appointments on time and payment of services rendered.
I am aware that I am responsible to pay any gap that my insurance does not cover.
In the event of a default on agreed upon payment arrangements, I am responsible for reasonable collection costs.
I have read and understand the terms and conditions.
I understand Dr Saba is a general Dentist with special interest in Orthodontics . I have been given the opportunity to seek opinion and / or treatment with Orthodontic Specialist.
I hereby authorize Dr. Amtul Saba to perform a complete orthodontic evaluation , collection of photographic and x-ray records and orthodontic treatment .

Layout

Signature (Parent if minor) *

Print full name

Date *

Dr Amtul Saba
17/254 Pitt St, Merrylands NSW 2160
Ph: 0296378077
E: [email protected]
https://beautifulsmiledentalsurgery.com.au/

DETAILED ORTHODONTIC HISTORY FORM

PATIENT DETAILS:

Parents/ Guardians:

INSURANCE DETAILS:

MEDICAL HISTORY:

DENTAL HISTORY

Contact Us

0296378077

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