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Rheumatic Fever
Heart Murmur
High Blood Pressure
Heart Attack/Stroke
Blood Vessel Disease
Blood Disorder
Blood Disorder
AIDS/HIV Infection
Hepatitis
Diabetes
Ulcers
Herpes (Any type)
Psoriasis
Cancer
Persistent Headache
Neck Pains
Nerve or Brain Disease
Migraine
Epilepsy
Mental Health Concerns
Bone Disorders
Arthritis (Any type)
Sleep Apnea
Ear Disorder
Sinus Infection
Swollen Glands
Allergies




Is the patient currently taking any medication?
Has the patient ever had a general anesthesia?
Has any other member of the family had orthodontic treatment?
other member of the family been a patient in this office
Are there other children in the family?







Asian
African-American
Caucasian/ European
East Indian
First Nations
Latin American
Unknown
Other


Asian
African-American
Caucasian/ European
East Indian
First Nations
Latin American
Unknown
Other


Asian
African-American
Caucasian/ European
East Indian
First Nations
Latin American
Unknown
Other








Male
Female



Yes
No