Medical and Dental History

Please Update Medical and Dental History

Patient Name

DOB

Today's Date

Physician

Phone

Date of Last Visit

Reason

Are you receiving medical care now?

Yes No

If yes, please explain.

Medications

Are you taking any medication(s) now? This includes prescription, over-the-counter medications, vitamins, and herbal remedies.

Yes No

If yes, please specify.

What is the purpose of these medications?

Do you have any drug allergies or sensitivities?

Yes No

If yes, please specify.

Have you ever taken bone density drugs?

Yes No

Do you have a latex allergy?

Yes No

Do you have any metal or jewelry allergy?

Yes No

Do you have any heart problems?

Yes No

If yes, please specify.

Do you have any prosthetic joints - i.e. hip, knee?

Yes No

Date of Replacements

Tobacco History

Do you currently use tobacco?

Yes No

Have you used tobacco in the past?

Yes No

If yes, when?

Are you interested in getting help to quit tobacco use?

Health History

Have you ever been hospitalized in the past 5 years? If yes, when and for what reason?

Are you being treated for any other medical condition not listed above? If yes, what?

Dental History

Do you use a TMJ or brux guard?

Diet

Do you consume any of the following more than once a week?

Candy

Sweetened Coffee or Tea

Cake, Cookies, or Sweet Desserts

Gum with Sugar

Non-diet Soda

Dried Fruit

Juice between meals

How often do you:

Brush your teeth

Floss your teeth

Do your teeth or gums bother you?

Yes No

If yes, please explain.

Do you ever notice mouth sores?

Are you happy with the appearance of your teeth? If not, why?

Do your have any problems with your jaw joints (TMJ)?

Yes No

If yes, please explain.

Do you have any dental concerns? If so, what are they?

Do you or have you had orthodontic treatment?

Yes No

If yes, name of Doctor.

Briefly explain treatment.

Do you play contact sports?

Yes No

Do you wake up tired in the morning?

Yes No

Do you weight lift (clench when lifting)?

Yes No

Do you have sleep apnea?

Yes No

Do you snore?

Yes No

Do you use CPAP?

Yes No

Can you breathe through your nose?

Yes No

Do you clench/grind your teeth?

Yes No

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Patient or Guardian's Signature

Home Phone Number

Cell Phone Number

Work Phone

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