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Medical History Form - Adult

About You

First name*

Last name*

I prefer to be called:

Gender*

Birthday*

Month

Day

Year

Age*

Email*

Phone*

Home Address*

How do you prefer we contact you to confirm appointments?*

Text

Email

Occupation*

Source of referral:*

General Dentist:*

Last visit date:*

Medical History

Do you have a physician?*

Yes

No

Physician's Name:

Are you currently being treated for a medical condition?*

Yes

No

If yes, please explain:

Are you taking any prescription/over the counter drugs?*

Yes

No

If yes, please list each one:

Do you smoke?*

Yes

No

Are you pregnant?*

Yes

No

If yes, how many weeks?

Have you ever had any of the following diseases or medical problems? Check all that apply.

Artificial Bones / Joints

Bone Disorders

Asthma

Arthritis

Diabetes

Heart Murmur

Congenital Heart Defect

Surgery / Heart defects

Hepatitis

HIV +/AIDS

Hospitalized for any reason

Psychological Problems

Epilepsy / Seizures

Other

Please list any serious medical condition(s)

Dental History

What are the main concerns that you would like orthodontics to accomplish?*

Have you ever been evaluated for or had any previous orthodontic treatment?*

Yes

No

If yes, please explain:

Have you ever had any facial or dental injuries?*

Yes

No

If yes, which teeth / part of your face was involved:

Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ / TMD)?*

Yes

No

Do you like your smile?*

Yes

No

Do your gums bleed?*

Yes

No

Please indicate whether you have any speech challenges:

Do you generally breathe through your mouth? Check all instances that apply:

Awake, resting state

Awake, exercising

Asleep

Unknown

Are you allergic to any of the following?

Dental Anesthetics

Any Metal/Plastic

Latex

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this

information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

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EVS Orthodontic Clinic

Dr. Edsard van Steenbergen, Inc.
DDS, MDS, PhD

Contact Us

info@evsortho.ca

Tel (250) 868-3488

Office Location

550 West Avenue, suite 321
Kelowna, BC V1Y 4Z4
Free parking available.

Opening Hours

Monday-Thursday: 7:30 am to 4:30 pm

Lunch Break: 1:00 to 2:00 pm

Friday-Sunday: Closed

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