MEDICAL HISTORY

    Is the patient presently under the care of a physician for any medical issue? : YesNo
    Is the patient currently taking medication? : YesNo
    Has the patient ever been hospitalized for surgery? : YesNo
    Does the patient have allergies to any food or medication? : YesNo

    Does the patient have a history of? (Please check all that apply)

    Heart Murmurs
    YesNo
    Diabetes
    YesNo
    Hearing Impairment
    YesNo
    Cancer/Tumors
    YesNo
    Muscle/Neural Problems
    YesNo
    Bone Problems
    YesNo
    Hormone Problems
    YesNo
    Heart Trouble
    YesNo
    Asthma
    YesNo
    Sinus Problems
    YesNo
    Chemo/Radiation Therapy
    YesNo
    Allergies
    YesNo
    Epilepsy
    YesNo
    Anemia
    YesNo
    Leukemia
    YesNo
    Allery/Sensitivity to Anesthesia
    YesNo
    Seizures/Convulsions
    YesNo
    ADD/ADHD
    YesNo
    Hepatitis
    YesNo
    Drug Sensitivities
    YesNo
    Recurrent Headaches
    YesNo
    Autism/Asperger’s
    YesNo
    Ear/Nose/Throat Problems
    YesNo
    High Temperature
    YesNo
    Eye Problems
    YesNo
    AIDS/ARC/HIV
    YesNo
    Blood Disorders
    YesNo
    Brain Injury/Concussion
    YesNo
    Lung Problems
    YesNo
    Kidney/Liver Involvement
    YesNo
    Urinary/Bladder Problems
    YesNo
    Vision Problems
    YesNo
    Artificial Prosthesis
    YesNo
    Nervous System Issues
    YesNo
    History of Blood Transfusion
    YesNo
    Premature Birth
    YesNo
    Congenital Birth Defects
    YesNo
    Hay Fever
    YesNo
    Chronic Cough
    YesNo
    Wheezing
    YesNo
    Cancer
    YesNo
    Stomach/Intestinal Problems
    YesNo
    High Blood Pressure
    YesNo
    Is there anything else regarding the patient’s physical, mental, or emotional health you feel we should know? YesNo

    Dental History

    Jaw or Face Injury:
    YesNo
    Broken Jaw
    Tooth Injury/Trauma:
    YesNo
    BrokenChippedLost
    Mouth Habits:
    YesNo
    Thumb/Finger SuckingLip/Tongue Habits
    Bleeding Gums:
    YesNo
    After BrushingAfter FlossingAll times
    Ever Had Speech Therapy?
    YesNo
    Jaw Joint Pain:
    YesNo
    Jaw Joint Popping/Clicking:
    YesNo
    Both SidesRight SideLeft Side
    Airway Problems
    YesNo
    Has the patient experienced any unfavorable reaction from previous medical or dental care? YesNo
    Treatment/Appointment Concerns:
    Please rate the following on a scale of 1 (Not Important) to 5 (Very Important)
    Length of Treatment:
    Comfort During Treatment:
    Clear/Invisible Treatment:
    Treatment Using the Latest Technology:
    Having a Low Down Payment:
    Having a Low Monthly Payment:
    Quality of Treatment:
    Starting Treatment within the Next Month:
    I understand and certify that the information I have given on this form is correct and that I am obligated to inform Reagin Orthodontics immediately if any of this information changes in the future.

    Signuture of Patient or Parent/Guardian if patient is a minor: