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Warren Orthodontics

688 West 400 South, Ste 100
Springville, UT 84663

(801) 489-7878

Mon: 9:00 AM–5:00 PM
Tue-Thrs: 8:00 AM–5:00 PM
Fri: 8:00 AM-3:00 PM

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    • 1 Patient 1

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Dental Medical History Form For Adult Patients


Marital Status

Are you aware that some appointments will be during school/work hours

Responsible Party/Spouse

Responsible Party Marital Status


Dual Coverage

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Medical History

Have you seen a physician in the last 12 months

Please mark any of the medical conditions you have had or currently have:

Dental Health

Have you had previous orthodontic treatment

If any of the dental questions are answered Yes, please explain

Are you presently in any dental pain

Have you ever experienced any unfavorable reaction to dentistry

ls any part of your mouth sensitive to temperature or pressure

Have there been any injuries to your face, mouth, or teeth

Do your gums bleed when you brush

Do you have any oral habits, such as tongue thrust or thumb sucking

Are you a mouth breather

Do your teeth or jaws ever feel uncomfortable when you wake up in the morning

Do you clench or grind your teeth

Do you have tension headaches

Has anyone in your family received orthodontic treatment? How did they feel about the result

Have you ever experienced chronic ringing in your ears

Women Only

Are you pregnant

Has menstruation started


Benefits of orthodontics: aesthetics, health, and function

Orthodontics is a service that provides an improvement in the appearance of the teeth, in the general function of the teeth, and in general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change throughout our lifetime, and there can be some movement of teeth and some change after treatment.

I have truthfully answered all of the above questions and agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Warren to perform a complete orthodontic evaluation.

Acknowledgment of Receipt of Notice of Privacy Practices