Medical History Form - Smile Network Staging

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PATIENT DETAILS

(To be completed by a Parent/Guardian if the patient is under 18 years of age)

To provide you with the highest standard of orthodontic care, it is essential to know your medical and dental history, as these factors may impact the success of your treatment. If you have any questions regarding the information we collect from you and hold in your records, please do not hesitate to ask us. We are acting in your best interest at all times. Please read our privacy policy for further information.

PATIENT DETAILS

Title

Name

First Name

Last Name

Address:

Street Address

Street Address line 2

City

State / Province

Postcode

City

Date of Birth

Gender

School (if applicable)

E-mail

Name of person completing this form

Relationship to patient Signature

Signature

Clear

Date of Birth

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HOW DID YOU HEAR ABOUT US?

Name/s of any other family members who have attended this practice?

What is your main reason for seeking this consultation?

Whom may we thank for your referral?

Name of your general dentist

Practice name/location

Phone number of your general dentist (if known)

When was your last appointment or last check-up? (If known)

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FOR THE PARENT/GUARDIAN

Parent 1

Mobile Number 1

Parent 2

Mobile Number 2

Guardian

Guardian Mobile

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PERSON RESPONSIBLE FINANCIALLY

Title

First Name

Last Name

Date of Birth

Address

Mobile Number

Private Health Fund (if applicable)

Email address (if different from above)

Signature

Clear

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PERSON RESPONSIBLE FINANCIALLY

Please indicate if you have confidential information that you want to discuss with the Orthodontist and not record on this form.

Yes

No

Has your child commenced puberty?

Yes

No

Has the patient inherited any facial or dental characteristics? (If yes, please detail)

Does the patient take any daily medications (including prescribed, over the counter, or naturopathic)? (If yes, please detail)

Any allergy to any medicines, chemicals, or other substances (latex, penicillin, peanuts, etc.)? (If yes, please detail)

Yes

No

If yes to above, please detail

Any other condlitions which may affect to undertake orthodontic treatment (please list)

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HAS THE PATIENT

Had any significant health problems in the past? If yes, please detail

Any current health problems? If yes, please detail

Any behavioural concerns that may preclude orthodontic treatment?

Yes

No

If yes to above, please detail

Had an orthodontic consultation previously?

Yes

No

Had any orthodontic treatment previously? If yes, please give details

Had an injury to the primary or permanent teeth? If yes, please give details

Had an injury to the face, jaws or chin? If yes, please give details

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HAS THE PATIENT EVER

Sucked his/her thumb or finger, or similar habit?

Yes

No

Experienced clicking, popping or grating sound from the jaw joint?

Yes

No

Experienced pain from the jaw joints or facial muscles?

Yes

No

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PATIENT DETAILS

PATIENT DETAILS

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HOW DID YOU HEAR ABOUT US?

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FOR THE PARENT/GUARDIAN

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PERSON RESPONSIBLE FINANCIALLY

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PERSON RESPONSIBLE FINANCIALLY

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HAS THE PATIENT

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HAS THE PATIENT EVER

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