(843) 871-4411 Schedule Consultation

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    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

      Have you ever been or currently on bisphosphonate medication? :YesNo

      Does the patient have any allergies to metal or nickel? :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

      Latex Allergy
      YesNo

      Metal Allergy
      YesNo

      Osteporosis
      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

      Has the patient recently been seen by an Orthodontist?YesNo

      Has the patient ever had a Consultation with an Orthodontist?YesNo

      Has the patient ever had braces?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: