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Home
About Us
Our Office
Dr Miller
Dr. Teel
Our Staff
First Visit
Our Services
Braces
Foods to Avoid
AcceleDent – Shortening Your Time in Braces
Incognito™
Damon Self Ligating Braces
Invisalign®
Silent Nite Sleep Device
Sleep Apnea
Retention
PROPEL® – Cut Your Time in Braces in Half!
Our Specials
Before & After
Resources
Affordable Financing
Office Hours
Contact Us
Map & Directions
Blog
Forms
New Patient Form
Medical History Form
HIPAA Consent Form
Receipt of Privacy Practices
Patient Referral Form
Wired Orthodontics
2225 Mission st SE, Suite 150,
Salem,
Oregon
97302
503.581.1569
Medical History Form
Home
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Medical History Form
Medical History Form
milleradmin
2014-05-09T04:06:25+00:00
Name
First
Last
Age
Sex
Male
Female
Who can we thank for referring you to us?
Dentist Referral
Patient Referral
Web search
Magazine ad
Online Ad
An insurance website
Directory website
Review website
Other website like Invisalign® or Lingual Braces®
Please let us know a little more...
Please let us know a little more about the referral. If it was a dentist who referred you, which one? If it was an ad, where did you see it?
Name and ages of children in the family:
Name
Age
Please use the "+" button to add rows
Medical History
Physician's Name
First
Last
Physician's City
Date of last exam
Date Format: MM slash DD slash YYYY
Please check all of the following for which the patient has been treated:
Diabetes
Heart Trouble
Rheumatic Fever
Bone Disorders
Hepatitis
Tuberculosis
Anemia
Epilepsy
Asthma
Kidney Problems
Endocrine Problems
Prolonged Bleeding
Fainting/Dizziness
Nervous Disorders
Liver Problems
Frequent Colds
Sore Throats
Ear Infections
Tonsils Removed
Adenoids Removed
List any drugs or medications now being taken; giving reason:
List any Allergies or drug sensitivities:
Dental History
Dentist’s Name
First
Last
Dentist's City
Date of last visit
Date Format: MM slash DD slash YYYY
Were X-rays taken?
Yes
No
Has the patient ever seen an orthodontist previously?
Yes
No
Has the patient ever worn orthodontic appliances?
Yes
No
Name of Orthodontist
First
Last
Has the patient ever sucked a thumb or finger?
Yes
No
Until what age?
Has the patient ever had any speech problems?
Yes
No
Any speech therapy?
Yes
No
Please explain:
Does the patient clench or grind teeth day or night?
Yes
No
Does the patient have pain or clicking upon opening and closing mouth?
Yes
No
Has the patient had any head or facial injuries?
Yes
No
Please explain:
Has any of the patient’s teeth been injured or chipped due to accidents?
Yes
No
Please explain:
Has the patient been informed of any missing or extra permanent teeth?
Yes
No
Please explain:
Is the patient a mouth breather?
Yes
No
In case of an emergency, contact:
First
Last
Phone
Phone
This field is for validation purposes and should be left unchanged.
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Best Care for Your Teeth!
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