Select Yes No Don't know/understand Birth defects or hereditary problems?
Select Yes No Don't know/understand Bone fractures, any major accidents?
Select Yes No Don't know/understand Rheumatoid or arthritic conditions?
Select Yes No Don't know/understand Endocrine or thyroid problems?
Select Yes No Don't know/understand Kidney problems?
Select Yes No Don't know/understand Diabetes?
Select Yes No Don't know/understand Cancer, tumor, radiation treatment or chemotherapy?
Select Yes No Don't know/understand Stomach ulcer or hyperacidity?
Select Yes No Don't know/understand Polio, mononucleosis, tuberculosis, pneumonia?
Select Yes No Don't know/understand Problems of the immune system?
Select Yes No Don't know/understand AIDS or HIV positive?
Select Yes No Don't know/understand Hepatitis, jaundice or liver problem?
Select Yes No Don't know/understand Fainting spells, seizures, epilepsy or neurological problem?
Select Yes No Don't know/understand Mental health disturbance or depression?
Select Yes No Don't know/understand Vision, hearing, tasting or speech difficulties?
Select Yes No Don't know/understand Loss of weight recently, poor appetite?
Select Yes No Don't know/understand History of eating disorder (anorexia, bulimia)?
Select Yes No Don't know/understand Excessive bleeding or bruising tendency, anemia or bleeding disorder?
Select Yes No Don't know/understand High or low blood pressure?
Select Yes No Don't know/understand Tired easily?
Select Yes No Don't know/understand Chest pain, shortness of breath or swelling ankles?
Select Yes No Don't know/understand Cardiovascular problem (heart trouble, heart attack, angina, coronary insufficiency, arteriosclerosis, stroke, inborn heart defects, heart murmur or rheumatic heart disease)?
Select Yes No Don't know/understand Skin disorder?
Select Yes No Don't know/understand Do you have a well-balanced diet?
Select Yes No Don't know/understand Frequent headaches, colds or sore throats?
Select Yes No Don't know/understand Eye, ear, nose or throat condition?
Select Yes No Don't know/understand Hayfever, asthma, sinus trouble or hives?
Select Yes No Don't know/understand Tonsil or adenoid conditions?

Allergies or reactions to any of the following:

Select Yes No Don't know/understand Local anesthetics (Novocaine or Lidocaine)
Select Yes No Don't know/understand Aspirin
Select Yes No Don't know/understand Ibuprofen (Motrin, Advil)
Select Yes No Don't know/understand Penicillin or other antibiotics
Select Yes No Don't know/understand Sulfa drugs
Select Yes No Don't know/understand Codeine or other narcotics
Select Yes No Don't know/understand Metals (jewelry, clothing snaps)
Select Yes No Don't know/understand Latex (gloves, balloons)
Select Yes No Don't know/understand Vinyl
Select Yes No Don't know/understand Acrylic
Select Yes No Don't know/understand Animals
Select Yes No Don't know/understand Foods  (specify)
Select Yes No Don't know/understand Other substances (specify)

Select Yes No Don't know/understand Is the patient taking medication, nutrient supplements, herbal medications or non prescription medicine? Please name them.

Medication   Taken For
Medication   Taken For
Medication   Taken For
Medication   Taken For
Medication   Taken For
Medication   Taken For
Medication   Taken For
Medication   Taken For

Select Yes No Don't know/understand Does the patient currently have or ever had a substance abuse problem?
Select Yes No Don't know/understand Does the patient chew or smoke tobacco?
Select Yes No Don't know/understand Operations?
Describe

Select Yes No Don't know/understand Hospitalized?
Describe

Select Yes No Don't know/understand Other physical problems or symptoms?
Describe

Select Yes No Don't know/understand Being treated by another health care professional?
For

Date of most recent physical exam?

Select Yes No Don't know/understand Do you have any other medical conditions that we should know about?

Girls Only:

Select Yes No Don't know/understand Has the patient started her monthly periods? If so, approximately when?
Select Yes No Don't know/understand Is the patient pregnant?

Select Yes No Don't know/understand Any pain, clicking or locking in jaw or ringing in the ears?
Select Yes No Don't know/understand Any pain or soreness in the muscles of the face or around the ears?
Select Yes No Don't know/understand Aware of loose, broken or missing restorations (fillings)?
Select Yes No Don't know/understand Any teeth irritating cheek, lip, tongue or palate?
Select Yes No Don't know/understand Concerned about spaced, crooked or protruding teeth?
Select Yes No Don't know/understand Aware or concerned about under or over developed jaw?
Select Yes No Don't know/understand “Gum Boils”, frequent canker sores or cold sores?
Select Yes No Don't know/understand Taking any forms of fluoride?
Select Yes No Don't know/understand Any relative with similar tooth or jaw relationships?
Select Yes No Don't know/understand Had periodontal (gum) treatment?
Select Yes No Don't know/understand Would the patient object to wearing orthodontic appliances (braces) should they be indicated?
Select Yes No Don't know/understand Had any serious trouble associated with any previous dental treatment?
Select Yes No Don't know/understand Ever had a prior orthodontic examination or treatment?
Select Yes No Don't know/understand Been under another dentist's care?
Specialist    Other