MEDICAL DENTAL HISTORY FORM FOR PATIENTS UNDER AGE 18
Other physicians/health care providers being seen now:
Your answers are for office records only, and are confidential. A thorough
medial history is essential to a complete orthodontic evaluation. FOR THE
FOLLOWING QUESTIONS MARK YES, NO, OR DON'T KNOW/UNDERSTAND (DK/U).
Now or in the past, have you had: (all fields are required)
Has your child ever taken intravenous bisphosphonates such as Zometa (zolendromic
acid), Aredia(pamidronate) or Didronel (etidronate) for bone disorders
Has your child ever taken oral bisphosphonates such as Fosamax (alendronate),
Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel
(etidronate) for bone disorders?
Has your child had allergies or reactions to any of the following?
Now or in the past, has the patient had: (all fields are required)
PATIENT HEALTH INFORMATION
List any medication, nutritional supplements, herbal medications or non-prescription
medicines, including fluoride supplements that your child takes.
Have your parents or siblings ever had any of the following health problems?
If so, please explain.
I authorize release of any information regarding my child’s orthodontic
treatment to my dental and/or medical insurance company.
I have read the above questions and understand them. I will not hold my
orthodontist or any member of his/her staff responsible for any errors
or omissions that I have made in the completion of this form. I will notify
my orthodontist of any changes in my child’s medical or dental health.