- 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?
- Have a pacemaker?
- A Bleeding or Blood Disorder?
- Acquired Immune Deficiency Syndrome?
- Alcohol or chemical dependency?
- Do they Smoke (including e-cigarettes)?
- Liver disease?
- Kidney disease?
- Breathing disorder?
- Treated for cancer?
- Thyroid disease?
- Artificial joints?
- Frequent colds or sore throat?
- History of thumb/finger sucking?
- Are they a mouth breather?
- Is there a speech problem?
- Noise and/or pain in jaw joint?
- Pain in jaw muscle?
- Do they have frequent headaches?
- Do they have clenching or grinding habits?
- Injuries to face or teeth?
- Do they have missing or extra teeth?
- Have they been advised to take antibiotics prior to dental treatment?
- Does the patient play a wind instrument?
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