1Patient Details

2Medical History

3Dental History

4Disclaimer

Comments

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Patient Details

First Name*

Last Name*

Date of Birth*

Gender*

Occupation

Address*

Address Address Line 2 City ZIP / Postal Code

Phone*

Email Address*

Medical History

Doctor's Name*

Have you had or do you have any of the following?

Please select the boxes that relate to you.

Rheumatic Fever

High Blood Pressure

Blood Vessel Disease

AIDS / HIV Infection

Kidney Trouble / Diabetes

Ulcers / Cold Sores / Herpes (any type)

Asthma

Mental Health Problems

Ear Disorder

Allergies

Heart Murmur

Heart Attack / Stroke

Blood Disorder / Anaemia

Hepatitis A, B or C

Gastric Problems

Persistent Head Aches / Migraine / Neck Pains

Nerve or Brain Disease

Bone Disorders

Sinus Infection

Cancer

Have you had any prosthetic surgery?*

ie. heart valves or hip replacements.

Yes

Are you presently, or have you ever been, under the care of a psychiatrist or psychologist?*

If yes, please describe.

Yes

Please describe your care under a psychiatrist or psychologist*

Are you allergic to any medications (e.g. aspirin, penicillin, etc)?*

If yes, what?

Yes

Please describe your allergies*

Have you ever had a general anaesthetic?*

If yes, when?

Yes

Please note when you had general anaesthetic*

Are you under a doctor’s care at present?*

If yes, please describe.

Yes

Please describe the care you are under with your doctor*

Are you currently taking any medication?*

If yes, please describe.

Yes

Please describe any medications you are currently taking*

Have you ever had your tonsils removed?*

If yes, when?

Yes

Please note when you had your tonsils removed*

Please note any other significant information about your medical history, including drug dependence.

Dental History

Dentist Name*

Date of Last Check Up*

Do you experience painful teeth?*

Please select the boxes that relate to you.

Yes

Upper right

Upper left

Lower right

Lower left

Have you experienced any of the following?*

Please select the boxes that relate to you.

Wisdom teeth removed

Injuries in the head and neck area

Surgery in the head and neck area

Noticed soreness, tightness or pain in the muscles around the jaws/ face

Treatment for periodontal disease (gum disease)

Fallen and bumped your chin, or received a blow to the jaws

Clenching or grinding of your teeth

Pain when chewing

Do you hear clicking (popping) or grating sounds in the jaw joints?*

Clicking

Grating

Both

Describe Clicking

Clicking

Left

Right

Both

Clicking

Began Gradually

Began Suddenly

Clicking Since When?

Clicking During What Activity?

Describe Grating

Grating

Left

Right

Both

Grating

Began Gradually

Began Suddenly

Grating Since When?

Grating During What Activity?

Was there some specific event that started the joint sounds?*

If yes, please describe.

Yes

Please describe the event that started the joint sound*

Have you ever experienced difficulty in opening or closing your jaws, or “locking” of the jaws open or closed?*

If yes, please describe.

Yes

Please describe the difficulty in opening or closing your jaws, or “locking” of the jaws open or closed*

Have you had pain in your jaw joints?*

Yes

Describe Jaw Joint Pain

Jaw Joint Pain

Left

Right

Both

Jaw Joint Pain

Began Gradually

Began Suddenly

Jaw Joint Pain Since When?

Jaw Joint Pain During What Activity?

What Increase the Pain?

What Decreases the Pain?

Do you have or have you had any of the following habits?*

Finger / Thumb sucking

Lip biting

Nail Biting

Has any other member of your family been a patient of this practice?*

If yes, please provide their name.

Yes

Family Member Name*

Have you had previous orthodontic treatment?*

If yes, please provide details.

Yes

When Did You Have Orthodontic Treatment?

Name of Orthodontist

Have you ever been treated for this problem before?*

If yes, please describe the diagnosis and treatment.

Yes

Diagnosis and Treatment

Please describe in your own words why you sought this consultation*

Disclaimer

Consent*

I, the undersigned, certify that I have read and understand the above medical and dental information, have reviewed it, and find it accurate. If there are any later changes to my clinical history, I recognise that it is my responsibility to inform this office. I also give my permission for a clinical examination and agree to take responsibility for associated fees.

I agree.

Signature*

New Patient Over 18

Patient Details

Medical History

Dental History

Describe Clicking

Describe Grating

Describe Jaw Joint Pain

Disclaimer