Gobeille Ortho

Patients Name*

FirstLast

Today's Date*

MM

DD

YYYY

Patients Gender*

Male
Female

Birth defects or hereditary problems?*

Yes
No

Any bone fractures or major accidents?*

Yes
No

Hay fever, asthma, sinus trouble or hives?*

Yes
No

Polio, mononucleosis, tuberculosis or pneumonia?*

Yes
No

Rheumatoid or arthritic conditions?*

Yes
No

Endocrine or thyroid problems?*

Yes
No

Problems of the immune system?*

Yes
No

Kidney problems?*

Yes
No

Hepatitis, jaundice or liver problems?*

Yes
No

Diabetes?*

Yes
No

AIDS or HIV positive?*

Yes
No

Cancer or treatment for tumor?*

Yes
No

Any sexually transmitted diseases?*

Yes
No

Fainting spells, seizures, epilepsy?*

Yes
No

Have you ever had a substance abuse problem?*

Yes
No

Mental health or behavioral problems?*

Yes
No

Do you use tobacco products?*

Yes
No

Vision, hearing, taste or speech difficulties?*

Yes
No

Dental History

Chipped or otherwise injured permanent teeth?*

Yes
No

Have any permanent teeth been removed?*

Yes
No

Teeth sensitive to hot or cold, teeth throb or ache?*

Yes
No

Any loose or broken fillings or restorations?*

Yes
No

Jaw fractures, cysts, mouth infections?*

Yes
No

Any irritation of cheek, lip, tongue or palate?*

Yes
No

“Dead teeth” or root canal therapy?*

Yes
No

Have you ever had periodontal (gum) treatment?*

Yes
No

Bleeding gums, bad taste or odor in mouth?*

Yes
No

Any relatives with similar tooth or jaw relationship?*

Yes
No

Periodontal or “gum” problems?*

Yes
No

Any wisdom tooth problems?*

Yes
No

Food impaction between teeth?*

Yes
No

Teeth grinding or clinching?*

Yes
No

What are your main concerns regarding the jaw and teeth?*

Please select all that apply.

Please detail:*

“Gum boils”, canker sores or cold sores?*

Yes
No

Thumb or finger sucking habits?*

Yes
No

Until what age?*

Please enter a value between 1 and 99.

Abnormal swallowing habit?*

Yes
No

Mouth breathing, snoring or difficulty breathing?*

Yes
No

Any pain in jaw or ringing in the ears?*

Yes
No

Clicking, popping, grating or grinding sounds in jaw joints?*

Yes
No

Have you ever experienced any pain or soreness in the muscles of your face or around the ears*

Yes
No

Have you ever been treated for TMJ problems?*

Yes
No

Difficulty encountered in chewing or opening jaw?*

Yes
No

Has your jaw ever locked open or closed?*

Yes
No

History of extra or congenitally missing teeth?*

Yes
No

Who was orthodontic consultation prompted by?*

Why are you seeking consultation?*

Please detail:*

Additional information:

Your E-mail Address:*

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Please confirm that you have read and understand the above questions.*

I will not hold my orthodontist(s) or any other member of their staff responsible for any errors or omissions that I may have made in the completion of this form. If there are any changes in my medical or dental history, I will inform this practice immediately.

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541-749-4444

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