Medical History

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.

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