Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Orthodontic Treatment Medical History Form
Patient Name *
Date of Birth
____ / ____ / ________
Previous Orthodontic Treatment
TMJ Symptoms
Oral Habits
Current Medications
| Medication | Dose | How often |
|---|---|---|
Missing or Extracted Teeth
Breathing Pattern
Family Orthodontic History
Orthodontic Treatment Medical History Form template from formisoft.com. formisoft.com/intake-templates/orthodontic-treatment-medical-history