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Online Medical History Form

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Before you visit us for your initial consultation appointment, you need to fill out a medical form. This can be done online here, or you can print out a copy from the forms section, fill it out by hand and bring it with you. If the form is not filled out before you visit us, you will need to fill it out at the practice, which will take up valuable time that could be better spent with the orthodontist.

Patient Information

First Name:* Middle Name: Last Name:* Date of Consultation (MM/DD/YYYY): Address:* Email:*

Mobile Phone Number:*

Home Phone Number:

Height:

Weight:

D.O.B. (MM/DD/YYYY):*

Patients GP:

Patients Dentist:

Referring Dentist:

Approximate date of last checkup:

Family Information (minors only):

Mother's Name:

Mother's Contact Number:

Father's Name:

Father's Contact Number:

Marital Status:

Single: Married: Separated: Divorced:

Medical History:

Is the patient in good health?:

Yes: No:

Has the patient been treated for any of the following?:

Anemia Fainting/Dizziness Nervous Disorders Asthma Glaucoma Pneumonia Bone Disorders Heart Disease Prolonged Bleeding Diabetes Hepatitis Rheumatic Fever Endocrine Problems Kidney Disease Tuberculosis Epilepsy Liver Disease Other

Does the patient have a tendancy for:

Sore Throats Colds Ear Infections

Have the tonsils been removed?:

Yes: No:

If so, at what age?: List any drugs or medications being taken currently: List any allergies or drug sensitivities: Has the patient reached puberty?:

Yes: No:

If so, at what age?: Has there been any injury to the mouth or teeth:

Yes: No:

Does the patient have any speech problems?:

Yes: No:

Has the patient ever sucked a thumb or fingers?:

Yes: No:

If so, at what age?: Reason for consultation:* Additional Information:

email

info@eastcoastorthodontics.ie

phone

(01) 697 91 84

address

Apt 7, Cubes 1, Beacon South Quarter,
Sandyford Industrial Estate, Dublin 18.
(map)

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