wbortho.com-NEW-PATIENT-MEDICAL-FORM

Medical-Dental History

Patient’s Name*

Patient’s Email*

Today’s Date *

MonthDayYear

1. Are you currently under the care of a physician for an existing condition?

YesNo

If yes, please explain:

2. Are you taking any prescription or over-the-counter medications?

YesNo

If yes, please explain:

3. Do you have any allergies?

YesNo

4. Have you been hospitalized within the past year for any reason?

YesNo

If yes, please explain:

5. Do you have or have you had any of the following conditions?

Arthritis

YesNo

Asthma

YesNo

Congenital Heart Defect

YesNo

Diabetes

YesNo

Heart Murmur

YesNo

Hepatitis

YesNo

Rheumatic Fever

YesNo

Severe/Frequent Headaches

YesNo

6. Has antibiotic pre-medication ever been required for dental treatment?

YesNo

If yes, please explain:

7. Have you ever had any injuries to the face, mouth or teeth?

YesNo

If yes, please describe

8. Have you been informed of any missing or extra permanent teeth?

YesNo

9. Do any of the following conditions exist?

Clenching or Grinding of Teeth

YesNo

Finger or thumb sucking

YesNo

Speech Problems

YesNo

E-Signature

Thank you for completing this form. It will enable us to care for you in a more effective manner.