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Youth Health and Dental History

Please, fill this form below.

Patient Details

Sex at Birth:
Do you have Orthodontic Insurance:

If yes, please provide details below:

Do you have additional coverage?

Health History

1. Are you in good health?
2. Do you have an history of major illness?
3. Do you have physical or other difficulties?
4. Are you under the care of a physician?
5. Do you have tonsil and/or adenoid problems?
6. Do you have any allergic reactions?
7. Are you taking any medications?
8. Do you have heart or circulatory problems?
9. Do you have a pacemaker?
10. Do you have or have you had Hepatitis?
11. Do you have a Bleeding or Blood Disorder?
12. Do you have Acquired Immune Deficiency Syndrome?
13. Do you have an alcohol or chemical dependency?
14. Do you smoke (including e-cigarettes)?
15. Do you have or have you had liver disease?
16. Do you have or have you had kidney disease?
17. Do you have a breathing disorder?
18. Have you ever been treated for cancer?
19. Do you have thyroid disease?
20. Do you have arthritis?
21. Do you have artificial joints?
22. Do you have frequent cold or sore throat?

Dental History

1. Are you a mouth breather?
2. Is there a speech problem?
3. Noise and/or pain in jaw joint?
4. Pain in jaw muscle?
5. Do you have frequent headaches?
6. Do you have teeth clenching or grinding habits?
7. Do you have injuries to face or teeth?
8. Do you have missing or extra teeth?
9. Have you been advised to take antibiotics prior to dental treatment?
10. Do you have an history of thumb/finger sucking?
11. Do you play a wind instrument?

I consent to the taking of x-rays, photographs and other necessary records before, during and after treatment for the purposes of planning, performing and evaluating 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.

PIease note that no data transmission over the internet can't be guaranteed to be 100% secure. As a resuIt, we cannot guarantee the security of any information you transmit to us over the internet, and you do so at your own risk. If you wouId prefer to contact us by teIephone to compIete this screening questionnaire, pIease caII: 604 892 5969

Thanks for submitting!

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