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Adult medical history

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Personal details

Title *
First name *
Middle name
Last name *
Gender *
Date of birth *
Address *
Suburb *
Postcode *
Home phone
Mobile phone
Work phone
Email *
Occupation
Preferred contact

Emergency Contact

Full Name
Relationship to Patient
Email
Phone

Doctor details

Medical practitioner
Family dentist
Referring dentist

Trauma

Have you ever had an accident involving teeth or jaw? *
Have you ever had clicking, noises, or pain in your jaw joints? *

Medical history

This may affect your orthodontic treatment. Please circle the correct answer and provide details when necessary.

Allergy to latex *
Heart or Kidney Disease *
Asperger’s, Autism, ADD, ADHD *
Allergies *
Asthma *
Blood pressure *
Anesthesia complications *
Psychiatric or Psychological care *
Diabetes, Epilepsy, Goitre etc *
Is there a possibility that you could be pregnant *
Prolonged bleeding after injury *
Serious operation *
Are you taking any medication *
Hepatitis or HIV *
Other *
Congenital heat disease or rheumatic fever *
Do you require antibiotic cover for dental procedures *
Further details, if necessary
Prone to fainting *

Sleep disturbance scale

At Smile Team Orthodontics we believe that all of our clients (both children and adults) should be screened before they consider orthodontic treatment because our treatment recommendations may differ in the presence of sleep apnea.

What is Obstructive Sleep Apnea? Sleep Apnea occurs when the walls to the throat close during sleep, causing breathing to stop. Once the brain registers that it is not breathing, the sleeper usually wakes up, rouses and the throat opens again, then they drift back to sleep. The person effected by sleep apnea, in most cases, does not realise they have even woken. It also causes decreased Oxygen Intake. This means the brain, heart and nervous system are not receiving their required time to rest and oxygenate. The pattern can repeat itself hundreds of times every night. One of the side effects of Sleep Apnea is Cardiac Problems. Also drivers with sleep apnea have 8 times the risk of car accidents.

Sudden Cardiac Death during sleep occurs more commonly in patients who have Obstructive Sleep Apnea.

Epworth Sleepiness Scale – for 17 years and older. Use the following scale to choose the most appropriate for each situation.

Sitting and reading *
Watching TV *
Sitting inactive in a public space *
Being a passenger in a motor vehicle for an hour or more *
Lying down in the afternoon *
Sitting and talking to someone *
Sitting quietly after lunch (no alcohol) *
Stopped for a few minutes in traffic while driving *

Referral

Have you had another member of your family treated in this practice? *
If YES what is the family member’s name?
Do you have a referral? *
Have you had a dental check up in the last 12 months? *

How did you hear about Smile Team Orthodontics? *

Please select ONE that may apply and provide details when necessary in box below.

If Specialist, please specify
If Friend, please name
If Member of Staff, please specify
If Relative, please name
If Other, please specify

Person responsible for paying for the orthodontic treatment

Name of person paying for treatment - Same as client details *

If NO please enter details below.

Title *
First name *
Last name *
Address
Postcode
Phone *
Email
Relationship to client
Date

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