Patient Forms

To save time at your first visit, please complete your patient form before your appointment. Choose either the Adult Patient Form or the Child & Teen Patient Form below.

Medical Dental History Form – Adult Patients (Responsive)

General Information

What concerns you about your teeth?

Who suggested you might need orthodontic treatment?

Why did you select our office?

Have you had any previous orthodontic treatment? Please describe.

Have any other family members been treated in this office? Please name them.

Do any of your work or leisure activities affect your teeth or jaws? Please explain.

Financial Responsibility

Who is Financially Responsible for this Account?

Address (if different from page 1)

City, State, Zip

Cell Phone

Home Phone

Email Address(es)

Social Security # / Employer

Dental Insurance

Primary Policy Holder

Full Name

Birth Date

Social Security #

Relationship to Patient

Address and Phone (if not listed above)

Employer

Employer Address

Insurance Company

Group #

ID #

Orthodontic benefits? Yes No Don't Know

Medical Insurance

Policy Holder's Full Name

Insurance Company

Your answers are for office records only and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, mark yes, no, or don't know/understand (dk/u).

Medical History — Now or in the Past, Have You Had:

	Yes	No	DK/U
Have you ever taken intravenous medication for bone disorders or cancer such as bisphosphonates (Zometa, Aredia, Didronel)?
Have you ever taken oral medication for bone disorders such as Fosamax, Actonel, Boniva, Skelid, Didronel?
Hereditary or developmental conditions?
Bone fractures or major injuries?
Any injuries to face, head, neck?
Arthritis or joint problems?
Endocrine or thyroid problems?
Diabetes or low sugar?
Kidney problems?
Cancer, tumor, radiation treatment or chemotherapy?
Stomach ulcer, hyperacidity, acid reflux?
Immune system problems?
History of osteoporosis?
Gonorrhea, syphilis, herpes, sexually transmitted diseases?
AIDS or HIV positive?
Hepatitis, jaundice or other liver problem?
Polio, mononucleosis, tuberculosis, pneumonia?
Seizures, fainting spells, neurologic problem?
Mental health disturbance or depression?
Vision, hearing, or speech problems?
History of eating disorder (anorexia, bulimia)?

	Yes	No	DK/U
High or low blood pressure?
Excessive bleeding or bruising, anemia?
Chest pain, shortness of breath, tire easily, swollen ankles?
Heart defects, heart murmur, rheumatic heart disease?
Angina, arteriosclerosis, stroke or heart attack?
Skin disorder (other than common acne)?
Do you eat a well-balanced diet?
Frequent headaches or migraines?
Frequent ear infections, colds, throat infections?
Asthma, sinus problems, hayfever?
Tonsil or adenoid condition?
Do you frequently breathe through your mouth?

Allergies or Reactions to Any of the Following?

	Yes	No	DK/U
Latex (gloves, balloons)
Metals (jewelry, clothing snaps)
Acrylics
Local anesthetics (novocaine, lidocaine, xylocaine)
Aspirin
Ibuprofen (Motrin, Advil)

	Yes	No	DK/U
Penicillin
Other antibiotics
Plant pollens
Animals
Foods
Other substances

Dental History — Now or in the Past, Have You Had:

	Yes	No	DK/U
Permanent or extra (supernumerary) teeth removed?
Supernumerary (extra) or congenitally missing teeth?
Chipped or injured primary or permanent teeth?
Any sensitive or sore teeth?
Bleeding gums, bad taste or mouth odor?
Jaw fractures, cysts, infections?
Any teeth treated with root canals or pulpotomies?
"Gum boils," frequent canker sores or cold sores?
History of speech problems or speech therapy?
Difficulty breathing through nose?
Food impaction between the teeth?

	Yes	No	DK/U
Mouth breathing habit or snoring at night?
History of speech problems?
Frequent oral habits (sucking finger, chewing pen, etc.)?
Teeth causing irritation to lip, cheek or gums?
Abnormal swallowing (tongue thrust)?
Tooth grinding or clenching?
Clicking, locking in jaw joints?
Soreness in jaw muscles or face muscles?
Ringing in ears, difficulty in chewing or opening jaw?
Have you ever been treated for "TMJ" or "TMD" problems?
Any broken or missing fillings?
Any serious trouble associated with previous dental treatment?
Have you ever been diagnosed with gum disease or pyorrhea?
Have you ever had an orthodontic consultation or treatment before now?

Patient Health Information

List any medication, nutritional supplements, herbal medications or non-prescription medicines.

Antibiotic pre-medication? Yes No

Medication

Taken For

Medication

Taken For

Have you ever taken medications to strengthen your bones?

Substance abuse problem?

How Often Do You Brush?

How Often Do You Floss?

Family Medical History

Bleeding Disorders

Diabetes

Arthritis

Severe Allergies

Other Family Medical Conditions

Release and Waiver

I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.

Signature

Date

I have read the above questions and understand them. I will not hold my orthodontist responsible for any errors or omissions.

Signature

Date

Medical History Updates or Changes

Changes

Patient Signature

Date

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

Medical Dental History Form – Under 18 (Full Responsive)

AAO

CONFIDENTIAL

Medical Dental History Form For Patients Under Age 18

Patient

Date

Patient's Last Name

First Name

Middle Initial

Prefers to be Called

Hobbies / Activities

Birth Date

Sex Assigned at Birth

Male Female

Current Gender Identification

Male Female Other

Preferred Pronouns

Social Security #

School

Grade

Email Address(es)

Home Address

City, State, Zip Code

Home Phone

Cell Phone

Parent / Guardian

Custodial Parent(s) Name(s)

Patient lives with:

Parent 1 Parent 2 Other

Parent 1 / Guardian

Full Name

Occupation

Email Address

Address (if different)

Cell Phone

Home Phone

Work Phone

Parent 2 / Guardian

Full Name

Occupation

Email Address

Address (if different)

Cell Phone

Home Phone

Work Phone

Dentist

Patient's Dentist

Address, City, State

Last Seen

Reason

Next Appointment

Other Dentists/Specialists: Name

City, State

Reason

General Information

What concerns you about your child's teeth?

What concerns your child about his/her/their teeth?

How does your child feel about orthodontic treatment?

Who suggested orthodontic treatment?

Why did you select our office?

Describe any previous orthodontic treatment.

Does your child play a musical instrument?

Sibling Orthodontic History:

Name	Age	Ortho?
		Yes No

Other family members treated in this office?

Financial Responsibility

Who is Financially Responsible?

Address (if different)

City, State, Zip

Cell Phone

Home Phone

SSN / Employer

Who brings patient to appointments?

Dental Insurance

Primary Policy Holder

Full Name

Birth Date

SSN

Relationship

Employer

Employer Address

Insurance Company

Group #

ID #

Ortho benefits? Yes No

Medical Insurance

Policy Holder Name

Insurance Company

Physician

Patient's Physician

City, State

Last Seen

Reason

Next Appointment

Most Recent Physical Exam

Other Physicians:

Name

City, State

Reason

Your answers are for office records only and are confidential.

Patient Health Information

Antibiotic pre-medication? Yes No

Substance abuse problem?

Medication

Taken For

Medication

Taken For

Does your child chew or smoke tobacco?

Medical History — Now or in the Past

Condition	Yes	No	DK/U
Emotional/developmental issues?
Hereditary conditions?
Bone fractures or major injuries?
Face/head/neck injuries?
Arthritis or joint problems?
Cancer/tumor/radiation?
Endocrine/thyroid problems?
Diabetes or low sugar?

Condition	Yes	No	DK/U
High/low blood pressure?
Excessive bleeding/bruising?
Chest pain/shortness of breath?
Seizures/neurologic problems?
Mental health disturbance?
Eating disorder?
Frequent headaches?

Dental History

How often does child brush?

How often floss?

Family Medical History

Bleeding Disorders

Diabetes

Arthritis

Severe Allergies

Other family medical conditions

Release and Waiver

I authorize release of any information regarding my child's orthodontic treatment.

Parent/Guardian Signature

Date

I have read the above questions and understand them.

Parent/Guardian Signature

Date

Medical History Updates or Changes

Changes

Parent Signature

Date

Changes

Parent Signature

Date

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.

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Young girl having an orthodontic examination

A close up of a person cutting a tooth with a pair of scissors.

Person with metal braces holding a clear aligner

Kendrick Orthodontics

Kendrick Orthodontics offers comprehensive orthodontic care including clear aligners, TMJ/ TMD care and Custom and Damon Braces for both children and adults in and around the following areas:

Medical Dental History Form for Adult Patients

Medical Dental History Form For Patients Under Age 18

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Kendrick Orthodontics