Online Health History Form

This is the online health history form for existing patients. If you are a new patient, please fill out either the adult or child new patient information form.

Please note that all of your responses will be encrypted and password-protected when you submit the form. Your responses are confidential and will never be stored on our website.
Health History Form

MEDICAL HISTORY

Full Name 

Date of Birth 

Physician 

Phone 

Physician's Address 

City 

State

Zip Code 

General Health and Known Illnesses 

Present Medications 

Surgeries (with approximate dates)

Is there a possibility that you may be pregnant? Yes  No 

Have you ever had an allergic reaction to medication? Yes  No 

If Yes, please list the medication(s) 

Have you ever had an allergic reaction to foods; latex; any metals, especially Nickel or Titanium, or any other substance? Yes  No 

If Yes, please list your allergy(ies) to any of the above mentioned 

Have you ever had any of the following:

Bleeding History: Yes  No 

Cancer: Yes  No 

Diabetes: Yes  No 

Hearing Loss: Yes  No 

Epilepsy: Yes  No 

Liver Problems: Yes  No 

High Blood Pressure: Yes  No 

Migraine Headaches: Yes  No 

Stomach Ulcers: Yes  No 

Hepatitis: Yes  No 

Kidney Problems: Yes  No 

AIDS or other immune system disorder: Yes  No 

Cardiovascular disease (heart trouble, heart attack, coronary insufficiency, coronary occlusion arteriosclerosis, stroke): Yes  No 

Damaged heart valves (Mitral valve prolapse, artificial heart valve, heart murmur) or any other conditions which may require you to be premedicated: Yes  No 

If yes to any of the above, does your condition require you to be premedicated? 

 

DENTAL HISTORY

Patient's Dentist 

Date of Last Visit (approx.) 

Dentist's Address 

City 

State 

Zip Code 

Have you previously consulted an orthodontist? Yes  No 

If yes, when and with whom? 

Have you consulted any other dental specialty? Yes  No 

If yes, when and with whom? 

Is there a history of congenitally missing teeth? Yes  No 

Patient  Relative(s) 

Do your gums bleed when you brush your teeth? Yes  No 

Is any part of your mouth sensitive to temperature? Yes  No 

Is any part of your mouth sensitive to pressure? Yes  No 

Have you ever sucked your thumb or finger(s)? Yes  No 

If so, have you stopped this habit? Yes  No 

Do you breathe predominantly through your mouth? Yes  No 

Have you had your tonsils/adenoids removed? Yes  No 

If Yes, when? 

Do you clench or grind your teeth during the day? Yes  No 

Have you been made aware of clenching or grinding your teeth during the night? Yes  No 

Do you now have, or have you ever had, pain in your jaw joint or the sides of your face (in and about the ears)? Yes  No 

Have you ever had clicking or popping in your jaw joint? Yes  No 

If Yes, please explain. 

Have you ever experienced pain when opening wide? Yes  No 

Have you had injury to your jaw? Yes  No 

If Yes, please explain. 

Have you had any injury to your teeth? Yes  No 

If Yes, please explain. 



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Brady Orthodontics

  • Brady Orthodontics - 80 W. Welsh Pool Rd., Suite 203, Exton, PA 19341 Phone: (610) 363-2200 Fax: (610) 594-9360