Minor Medical History - Schellinck

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Minor Medical History

Please fill out information below to the best of your ability.

MEDICAL HISTORY

Patient's Name

First Last

Name of Patient's Physician

Is the patient currently in good health?(Required)

Yes

No

If no, why?

Does the patient have regular annual medical exams?(Required)

Yes

No

Is the patient up to date with immunizations?(Required)

Yes

No

Is the patient currently taking any medications?(Required)

Yes

No

If yes, please list:

Does the patient have any allergies? (medications, food, latex/rubber)(Required)

Yes

No

If yes, please list

Has the patient ever been hospitalized?(Required)

Yes

No

If yes, when and why?

Has the patient had any operations/surgeries?(Required)

Yes

No

If yes, when and why?

Has the patient ever had general anesthesia?(Required)

Yes

No

If yes, were there any complications?(Required)

Yes

No

If yes, please explain:

Has the patient experienced, have or had any of the following?

Anemia

Arthritis, rheumatism

Chronic allergies

Asthma

Blood disorder

Canker or cold sores

Diabetes

Chronic ear infections

Eating disorder

Fainting spells

Severe Fever

Chronic Headaches

Hearing problems, ear pain

Heart attack

Treatment for emotional, mental, or physical delays

Heart disease /defects / murmurs

Hepatitis

High blood pressure

Jaundice

Kidney or bladder disease

Persistent cough or runny nose

Seizures

Sexual transmitted disease

Skin disease

Stomach problems or ulcers

Thyroid disease

Transplants

Tuberculosis

Tumors or cancer

Anxiety & Depression

Does the patient have or has he/she had any other diseases or medical problems NOT listed on this form?(Required)

Yes

No

If yes, please explain

DENTAL HEALTH HISTORY

Name of patient’s Dentist

Approximate date of patient’s last dental cleaning

MM slash DD slash YYYY

Approximate date of last dental radiographs (X-rays)

MM slash DD slash YYYY

Does the patient respond well to his/her dentist:(Required)

Yes

No

If no, please explain:

If the patient left his/her previous dentist, what was the reason?(Required)

Yes

No

Please Explain

Has the patient ever had problems with prior dental treatment?(Required)

Yes

No

Please Explain

Has the patient experienced, have or had any of the following?

Injuries to the face, mouth, or teeth

Thumb, finger, or pacifier sucking

Missing or extra permanent teeth

Mouth breathing, snoring, enlarged adenoids or tonsils

Habits (cheek biting, lip biting/sucking, tongue thrusting)

Speech problems

Habit of going to bed with a bottle

Jaw pain, clenching or grinding of teeth (day or night)

How often does the patient brush his/her teeth?

How often does the patient floss his/her teeth?

Has the patient had a previous orthodontic consult or orthodontic treatment?(Required)

Yes

No

If yes, please explain

Please list the main reason for this visit

What are your goals in coming to our practice?

What would you most like to accomplish for the patient?

Patient or Guardian Signature(Required)

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1855 San Miguel Dr., Suite 14 Walnut Creek, CA 94596
Tues-Fri 8:00-5:00
925.300.3619

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