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Adult Patient Personal Information

Dental History

Have you seen an Orthodontist before?
Have you ever required antibiotics or other medications prior to dental treatment?

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.

Jaw joint problems?
Grinding and/or clenching of teeth?
Thumb/finger sucking?
Injury to face or teeth?
Tongue position or swallowing problems?
Tonsils or adenoids removed?
Speech/articulation problems?
Any difficulty chewing?
Any difficulty with speech?
Mouth breathing more than nose breathing?

Medical History

Are you currently under medical care?

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.

Nickel/Metal allergy?
Latex allergy?
Rheumatic fever?
Epilepsy or Seizures?
Hereditary problems?
Asthma?
Headaches?
Hepatitis?
Heart murmur?
Heart problems?
H.I.V. positive?
Diabetes?
Anemia?
Prolonged bleeding?
Snoring or Sleep Apnea?

Dental Insurance Information

I consent to having Dr. Lorne Kamelchuk do a clinical orthodontic examination and photographic documentation.
I consent to the discretionary and anonymous use of my clinical photos and x-rays for Dr. Lorne Kamelchuk's educational/teaching purposes.

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