Medical/dental questionnaire

Your current dentist's name
Your current dentist's address
Last dental visit
Number of dental X-rays in the last two years
Have you ever consulted an orthodontist?
When?
Do you play a musical instrument?
If so, which instrument?
Have you ever had an accident on your head or face?
Have you ever had a dental trauma (fracture, blow to teeth, etc.)?
Have you ever had a head, face, jaw or mouth operation?
Have you ever had orthodontic treatment?
Have you ever had teeth extracted for orthodontic reasons?
Do you have difficulty opening your mouth?
Does your jaw "crack"?
Do your gums bleed?
Do you have sensitive teeth?

Your family doctor's name
Your family doctor's address

Are you currently under the care of a doctor?
If so, why?
Do you take any medication or have you taken any in the last 6 months?
If so, which medication?
Are you taking the birth control pill?
Teenagers: At what age did you have your first menstrual period?
Teenagers: At what age did your voice begin to change?
Are you pregnant?
Do you smoke?
Have you ever had an allergic reaction to a drug, food, nickel or other substance?
If so, which substance?
Have you ever been hospitalized?
If so, why?

Other relevant medical or dental information