Sex at Birth*MaleFemale

Patient's Full Name*

Patient's Date of birth*

Patient's Age*

Patient's Phone*

Patient's Email*

Patient's Address*

Who recommended you to our practice?

Health Fund*

Has any other member of the family attended our surgery?*YesNo

If yes, Name of family member:

Name of Dentist*

Location of Dentist*

Have you ever had orthodontic treatment in the past or a previous orthodontic consultation?YesNo

If yes, details

Do you clench/grind your teeth? YesNo

When:

Do you have a nail biting habit?YesNo

Do you suck your thumb or fingers?YesNo

Do you normally breath through your;Your noseYour mouth

Has there been any major change in your health recently?YesNo

If yes, please give details

Are you currently taking any medications?YesNo

If yes, what is this medication taken for?

Have you ever had your tonsils/adenoids removed?YesNo

If yes, please give details

Do you smoke? *YesNo

If yes, how many cigarettes per day?

Do you take any medication for osteoporosis or cancer treatment? *YesNo

Do you take Fosamax or any Bisphosphonates? *YesNo

Has the patient been diagnosed with Autism? *YesNo

Has the patient been diagnosed with ADHD – Learning / Behavioural Difficulties? *YesNo

Has the patient been diagnosed with Anxiety, Depression, or mood Disorders? *YesNo

Have any accidents occurred that caused any of the following:

I consent to my orthodontic records being used for dental education and training purposes. The identity of patients will not be disclosed.YesNo

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

I understand that less than 24 hours notice given to cancel my initial scheduled appointment or failure to attend, the consultation fee of $150.00 will need to be prepaid prior to rescheduling my initial consultation.

Date*

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Adult Medical History Form

Dental history

Orthodontic concerns

Dental trauma

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Harris Orthodontics