Myofunctional Medical History: 8yo and Up

FORM COMPLETED BY:

DATE COMPLETED:

PATIENT’S FULL NAME:

DATE OF BIRTH:

SEX:

MALE FEMALE

GENDER:

PRONOUNS:

HOME ADDRESS (street, city, state, and zipcode):

MAIN PHONE NUMBER:

PREFERRED METHOD OF CONTACT:

HOME CELL EMAIL

DIAGNOSIS:

ALLERGIES/PRECAUTIONS:

PRIMARY LANGUAGE SPOKEN AT HOME:

Insurance Carrier

Insurance ID Number:

Insurance Group Number:

Insurance Policyholder Name:

Insurance Policyholder Date of Birth:

Insurance Policyholder Relationship to Patient:

Referral Source:

PARENT / PRIMARY CAREGIVER INFORMATION:

Parent 1 Name:

Parent 1 Date of Birth:

CELL PHONE:

Okay to leave messages?

Yes No

EMAIL ADDRESS:

Sex:

Male Female

RELATIONSHIP TO CHILD:

Biological Adoptive Step Foster Other

Parent 2 Name:

Parent 2 Date of Birth:

CELL PHONE 2:

Okay to leave messages?

Yes No

Sex:

Male Female

RELATIONSHIP TO CHILD:

Biological Adoptive Step Foster Other

PRIMARY DOCTOR AND CLINIC:

EMERGENCY CONTACT INFORMATION (other than parent/primary caregiver):

NAME:

PHONE NUMBER:

PHONE NUMBER 2:

RELATIONSHIP TO CHILD:

ADDRESS:

DENTAL HISTORY INFORMATION:

DENTIST NAME:

NAME AND ADDRESS OF DENTAL PRACTICE:

PHONE NUMBER / FAX NUMBER:

NAME OF ORTHODONTIST:

NAME AND ADDRESS OF ORTHODONTIST PRACTICE:

PHONE NUMBER / FAX NUMBER:

I. TEETH

Are you presently wearing braces?

Yes No

If yes, for how long?

When will you get them off?

If no, have you worn braces before?

Yes No

If Yes, when?

If no, are you going to be getting braces?

Yes No

If Yes, when?

Are you presently wearing, or have you worn, any of the following? (write in dates)

Headgear

Elastics

Palatal Expander

Retainers

Positioner

Other

Briefly describe your teeth before you got your braces:

If you have braces, has your orthodontist ever expressed difficulty in getting your teeth to move or stay properly?

Yes No

Please explain:

Comments:

II. EATING AND DRINKING

Here is a question for your mother: Did your son/daughter ever have difficulty nursing, taking a bottle, or eating when an infant?

Yes No

Please explain.

Comments:

III. RESPIRATION

Please explain allergies/asthma and any medications used.

Tonsils removed? Please list date.

Adenoids removed? Please list date.

Comments:

IV. THUMB/FINGER SUCKING

I presently suck my thumb or fingers:

I want to stop I don’t really want to stop

I have sucked my thumb or fingers in the past; Here is how I stopped:

Comments:

V. SPEECH

Speech problems

No, I do not have a speech problem

I have had a speech problem in the past (explain below)

Yes, I currently have a speech problem (explain below)

I have had speech therapy (explain below)

I have not had speech therapy (explain below)

Please explain any speech problems and speech therapy here.

Comments:

VI. JAW OR FACIAL PAIN

What providers have you seen for the pain?

What aggravates your pain?

What makes it feel better?

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