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New Patient Medical History Form

Medical History Form – Dr Debora Harris (Specialist Orthodontist)

Please take your time to answer these questions as completely as possible. It will assist us greatly in our effort to provide the best care for you. All information provided will be kept completely confidential.

Fields marked * are required.

Patient’s First Name*

Patient’s Last Name*

Date of birth*

Patient’s Occupation*

Patient’s phone number*

Patient’s email*

School (if student)

Patient’s Address*

Mother’s Full name (patients under 18 years)

Mother’s Phone number

Mother’s Email

Mother’s Occupation

Father’s Full name (patients under 18 years)

Father’s Phone number

Father’s Email

Father’s Occupation

Who recommended you to our practice?

Dentist

Dr Name, Practice name and location

Friend

Our Website

Google reviews

Surgery Signage

Facebook / Instagram

YouTube

Sibling

School Newsletter

Other

Health Fund name / number?*

Has any other member of the family attended our surgery?* Yes No

If yes, Name of family member:

Dentist if different from above

(Name) Dr:

Practice name and location

Date of last consult

Have you ever had orthodontic treatment in the past or a previous orthodontic consultation?* Yes No

If yes, please provide details:

What are your main concerns today? Please list all (irregular teeth, appearance, facial profile concerns, jaw pain etc…)*

Do you clench/grind your teeth? Yes No

When:

Do you suck your thumb or fingers? Yes No

Have you ever had any jaw/joint problems? Yes No

If yes, please tick the appropriate below;

Inability to open/close jaw? Yes No

Pain? Yes No

jaw / joint noises? Yes No

jaw / joint clicking? Yes No

jaw / joint popping? Yes No

ringing in ears? Yes No

Do you normally breath through your;* Your nose Your mouth

Difficulty Sleeping?* Yes No

Are you currently taking any medications?* Yes No

PLEASE LIST ALL MEDICATIONS EVEN IF YOU THINK IT IS NOT RELEVANT TO ORTHODONTICS (please list if you are taking Fosamax or Bisphosphonates)

Have you ever had your tonsils/adenoids removed or consulted an ENT specialist recently?* Yes No

If yes, please give details

Do any of the following conditions apply to you?

Heart Problems

Haemophilia

Diabetes

Osteoporosis

Leukemia

Rheumatic Fever

Arthritis

Bone Disorders

Depression

Anxiety

Bipolar disorder

Schizophrenia

Thyroid Problems

Epilepsy

Hepatitis (A)

Hepatitis (B)

Hepatitis (C)

Kidney Disease

Bleeding problems

Asthma

HIV/AIDS

Liver Disease

Sinus problems

ADD/ADHD

Learning Difficulties

Allergies

Hypersensitivity

Sleep apnoea

Autism Spectrum

Other - Please list any other illnesses or conditions or provide details of any of the above conditions.

I consent to my orthodontic records being used for education, publishing, or training. The identity and face of patients will not be disclosed.* Yes No

I certify that the above medical history is accurate currently. If there are any future changes, I will inform Dr Debora Harris.

Date*

Signature - (Patient / Parent / Guardian)

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Harris Orthodontics

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Harris Orthodontics

Suite 19-21, Level 1
The Exchange Building
1 Elyard Street
Narellan NSW 2567

1800 0 678 46 (1800 0 ORTHO)

reception@harrisortho.com.au

Monday 8:00am - 5:00pm

Tuesday 8:00am - 5:00pm

Wednesday 8:00am - 5:00pm

Thursday 8:00am - 5:00pm

Friday 8:00am - 5:00pm

Saturday Closed

Sunday Closed

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