Patient Medical History

Patient Name

Date of Birth

Instruction: Please check the appropriate answer to the question. (Leave blank if you do not understand the question):

1. Are you under medical treatment now?

Yes No

2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?

Yes No

If yes, please explain:

3. Are you taking any medication (Including non-prescription medicine)?

Yes No

If yes, please list all medications you are taking:

4. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than three weeks?)

Yes No

5. Are you required to take prophylactic antibiotics before dental treatment?

Yes No

6. Do you use tobacco?

Yes No

How many times per day?

7. Do you use recreational drugs?

Yes No

8. Do you use alcohol?

Yes No

9. Are you allergic to or have had any reactions to the following?

Penicillin

Local Anesthetics

Aspirin

Any metals

Other

If other, please specify:

10. Women Only:

A. Are you pregnant or think you may be pregnant?

Yes No

B. Are you nursing?

Yes No

C. Are you taking oral Contraceptives?

Yes No

Other, please specify:

12. Do you have any other medical or health conditions which are not listed?

Yes No

If yes, please list below:

PATIENT DENTAL HISTORY

Name of Previous Dentists and Location

Date of Last Exam

1. Do you feel pain to any of your teeth?

Yes No

2. Do your gums bleed while brushing or flossing?

Yes No

3. Are your teeth sensitive to sweet or sour liquids/foods?

Yes No

4. Are your teeth sensitive to hot or cold liquids/foods?

Yes No

5. Do you have any sores or lumps in or near your mouth?

Yes No

6. Have you had any head, neck, or jaw injuries?

Yes No

7. Have you ever experienced any of the following problems in your jaw?

Clicking

Pain (joint,ear, side of face)

Difficulty in opening or closing

Difficulty in chewing

8. Do you have frequent headaches?

Yes No

9. Do you clench or grind your teeth?

Yes No

10. Do you bite your lips or cheeks frequently?

Yes No

11. Have you ever had difficult extractions in the past?

Yes No

12. Have you ever had any prolonged bleeding following extractions?

Yes No

13. Have you had any orthodontic treatment?

Yes No

14. Do you wear dentures or partials?

Yes No

If yes, date of placement:

15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

Yes No

16. Do you like your smile?

Yes No

AUTHORIZATION

I certify, that to the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/ or medication.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Signature

Date

Your information will be encrypted.

Patient Medical History

PATIENT DENTAL HISTORY

AUTHORIZATION

BROADWAY SMILES DENTIST