Tooth Fairy Dental on Eglinton

Orthodontic Intake Form - Adult

161 Eglinton Ave E, Unit 1, Toronto, ON M4P 1J5      416-546-9870

Welcome to Tooth Fairy Dental on Eglinton

Personal Information

Patient's Name:
Patient's E-mail:
Patient's D.O.B.
Age:
Gender Identity
Street:
City:
Province:
Postal Code:
Tel. Home:
Tel. Cell:
Patient's Dentist:
Last Appointment Date:
Patient's Physician:
Physician's Tel:
Patient's Occupation:
Person Responsible for the Account:
Relationship:
Is the Patient Covered by Orthodontic Insurance?
Emergency Contact:
Phone Number:

Medical History

Have you been treated for any of the following?
YesNo YesNo
Frequent Colds Leukemia/Cancer
ADD / ADHD Tuberculosis
Rheumatic Fever Endocrine Problems
Autism Spectrum Asthma
Heart Murmur/Heart Disease H.I.V. / A.I.D.S.
Emotional Disorder Tonsillitis
Prolonged Bleeding/Blood Disease Hepatitis A, B, or C
Artificial Heart Valve Adenoids
Learning/Behavioral Condition Diabetes
Eczema Other
Liver Disease/Jaundice Epilepsy
Vision Problems Kidney Disease
Bone Disorders Mouth-breathing
If you checked off any of the above please give pertinent details:
Are you currently being treated for any medical conditions?
If yes, please explain:
List any drugs or medications being taken (Please give reason):
Do you have any history or major illness and/or operations?
If yes, please explain:
List any allergies or drug sensitivities:
Have tonsils or adenoids been removed? If so at what age?
Do you have a tendency to cold sores, sore throats, or ear infections? (Please list):

Dental History

Have you ever been treated for a jaw joint problem, including surgery?
Have there been any injuries to the face, mouth, teeth?
If yes, please describe:
Have you had a history of thumb-sucking or finger-sucking?
If yes, age stopped:
Do you have any speech problems?
Are you a mouth-breather?
Have you consulted an orthodontist previously?
Have you had any previous orthodontic treatment?
If yes, please clarify:
Please check if there is a history of:
YesNo YesNo
Clenching teeth Headaches (more than normal)
Jaw joint popping Jaw joint soreness
Grinding teeth Muscular soreness around head and neck
Ringing in ears Jaw joint clicking
Is there other information that may be helpful?
Reason for this orthodontic consultation:

Signature