MEDICAL HISTORY

    Are you in good health?: YesNo

    Have you experianced any of the following:

    For all yes answers please provide specifics below:

    Sinus Problems:
    YesNo
    Ear/Nose/Throat Problems:
    YesNo
    Eye Problems:
    YesNo
    Muscle/Neural Problems:
    YesNo
    Bone Problems:
    YesNo
    Hormone Problems:
    YesNo
    Blood Problems:
    YesNo
    Kidney/Liver Problems:
    YesNo
    Urinary/Bladder Problems:
    YesNo
    Stomach/Intestinal Problems:
    YesNo
    Heart/Lung Problems:
    YesNo
    Head/Neck Problems:
    YesNo
    Back/Shoulder Problems:
    YesNo

    Alergies:

    MetalLatex
    Drugs (Please List)
    Foods (Please List)
    Other (Please List)

    Please check any that applay:

    Airway Problems

    SnoringGrinding TeethSleep ApneaMouth BreathingClenchingBed Wetting

    Heart Problems

    MurmurHigh Blood PressureChest PainHeart Valve ProblemAnginaHeart Failure/AttackPalpationsCoronary Disease

    Breathing Problems

    AsthmaHay FeverWheezingChronic Cough

    Chronic Diseases

    TuberculosisHepatitis AHepatitis BHepatitis CCancerDiabetesHIV/AIDS

    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

    Fun stuff about you:

    Select your preferred method of orthodontic treatment:
    Metal BracesClear BracesClear Aligners (ex: Invisalign)
    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: