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Orthodontic Treatment Medical History Form
Medical History

Orthodontic Treatment Medical History Form

2 pages•17 fields•HIPAA-ready
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Orthodontic Treatment Medical History Form

Orthodontic Treatment Medical History Form

Page 1 of 2

Patient Name
Jane Martinez
Date of Birth
03/15/1985
Previous Orthodontic Treatment
Option A
Option B
Option C
TMJ Symptoms
Fatigue
Pain
Nausea
Dizziness
Shortness of breath
Oral Habits
Current Medications
Missing or Extracted Teeth
Enter details here...
Breathing Pattern
Option A
Option B
Option C
Family Orthodontic History
Enter details here...
Submit
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This Orthodontic Treatment Medical History Form provides orthodontists with essential patient information specific to teeth alignment, jaw development, and comprehensive orthodontic care planning. The form captures detailed information about previous orthodontic treatment, retained primary teeth, oral habits like thumb sucking or tongue thrusting, and temporomandibular joint (TMJ) symptoms that may impact treatment planning. Healthcare providers can identify contraindications to tooth movement, assess bone density concerns, and evaluate systemic conditions affecting orthodontic outcomes.

Tailored for orthodontic specialists, pediatric dentists offering orthodontic services, and multi-specialty dental practices, this template includes sections for growth and development history, previous dental trauma, breathing patterns, and family history of malocclusion. The form documents medication use that may affect bone remodeling, previous extractions or missing teeth, and patient concerns about smile aesthetics. Comprehensive oral habit documentation helps orthodontists develop customized treatment plans for braces, clear aligners, palatal expanders, and other orthodontic appliances while considering medical factors that influence treatment duration and success.

What's included

  • Previous orthodontic treatment details
  • TMJ disorder symptoms
  • Oral habits assessment
  • Breathing pattern evaluation
  • Growth and development history
  • Dental trauma history
  • Missing teeth documentation
  • Medication review for bone health
  • Family malocclusion history
  • Treatment expectations and concerns

Who uses this template

  • Orthodontic specialty practices
  • Pediatric dentistry with orthodontics
  • Multi-specialty dental groups
  • Clear aligner providers
  • Orthognathic surgery centers

All form fields

9 fields across 2 pages. Customize any field after signing up.

Patient NameText
Date of BirthDate
Previous Orthodontic TreatmentMultiple Choice
TMJ SymptomsCheckbox
Oral HabitsCheckbox
Current MedicationsMedications
Missing or Extracted TeethLong Text
Breathing PatternMultiple Choice
Family Orthodontic HistoryLong Text
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