Patient Forms

ADULT HEALTH HISTORY FORM (PRINT AND BRING IN)

Adult Health History Form

MM slash DD slash YYYY
Name
MM slash DD slash YYYY
Please enter a number from 1 to 120.

MEDICAL HISTORY

General Health
Adopted Child
Adenoids (removed)
Allergies
Blood/Bleeding Problems
Bone disorder
Diabetes
Ear/nose infections
Emotional
Endocrine disorder
Epilepsy
Fainting Spells
Glaucoma
Hepatitis
Heart Murmur
Hospitalized
Hyperactivity
Learning Disability
Liver disorder
Lung disorder
Rheumatic fever
Scoliosis
Speech Difficult
Tonsils (removed)
Venereal disease

DENTAL HISTORY

Bruxism: (grinds teeth)
Jaw point (TMJ problems)
Speech: difficulty in pronunciation
Speech lessons
Have you had any experience with or seen another orthodontist?
This field is for validation purposes and should be left unchanged.

CHILD HEALTH HISTORY FORM (PRINT AND BRING IN)

Child Dental and Medical History

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Hinesly Orthodontics

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Hinesly Orthodontics combines art, science and expertise to provide the highest level of orthodontic care possible.

young child gets piggyback rides

Video Testimonials

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Patient Review

See what people in the Ann Arbor and Tecumseh areas are saying about Hinesly Orthodontics! Read reviews from real patients or leave one of your own.

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