- Are you in good health?
- History of major illness?
- Physical or other difficulties?
- Under the care of a physician?
- Tonsil and/or adenoid problems?
- Any allergic reactions?
- Taking any medications?
- Heart or circulatory problems?
- Do you have a pacemaker?
- Do you have or have you had Hepatitis?
- Do you have a Bleeding or Blood Disorder?
- Do you have Acquired Immune Deficiency Syndrome?
- Alcohol or chemical dependency?
- Do you Smoke (including e-cigarettes)?
- Do you have or have you had liver disease?
- Do you have or have you had Kidney disease?
- Do you have a breathing disorder?
- Have you ever been treated for cancer?
- Do you have thyroid disease?
- Do you have arthritis?
- Do you have any artificial joints?
- Women only: Are you pregnant or nursing?
- Are you a mouth breather?
- Is there a speech problem?
- Noise and/or pain in jaw joint?
- Pain in jaw muscle?
- Do you have frequent headaches?
- Do you have teeth clenching or grinding habits?
- Injuries to face or teeth?
- Do you have missing or extra teeth?
- Have you been advised to take antibiotics prior to dental treatment?
I grant permission for Mountain Orthodontics to share pertinent information with other medical, dental, and insurance professionals as it relates to the patient’s orthodontic treatment and overall dental care.
I authorize release of information from my insurance company as it relates to the patient’s dental/orthodontic claims, benefits, pre-determinations and coverage.
To the best of my knowledge, I have answered all questions accurately and truthfully.
I understand that providing incorrect information may be dangerous to the patient’s health. I also agree to inform the Orthodontist and/or staff member of any changes in the patient’s medical status or other pertinent information.
Please note that no data transmission over the internet can be guaranteed to be 100% secure. As a resuIt, we cannot guarantee the security of information you transmit to us over the internet, and you do so at your own risk. If you wouId prefer to compIete this form in person, prior to your appointment, pIease caII: 604-892-5969