Patient Dental & Medical Health History Information

To our patients: Please know that we may ask follow-up questions to make sure we have all of the information we need in order to treat you.

PATIENT INFORMATION

Last Name

First Name

Middle

Home Phone No.

Cell Phone No.

Work Phone No.

Email address

Mailing Address

City

State

Zip Code

Date of Birth

Gender

Occupation

Emergency Contact Name

Relationship

Phone No.

If you are completing this form for another person, what is your name and relationship to that person?

Name

Relationship

If executing this form as the patient's personal representative, I represent and warrant that I have full legal right and authority to consent to the performance of any procedure(s) on this patient. If for any reason I no longer have such legal right and authority, I will immediately notify the practice in writing.

How did you hear about us/were you referred to us by anyone in particular?

Please State your Dental Insurance Provider/ ID Number/ Group Number

DENTAL HISTORY AND SYMPTOMS

What is the reason for your visit today?

If yes, Where?

When was your last dental exam?

What was done at that appointment?

When was the last time you had dental x-rays taken?

Please mark “Check” in the box ONLY if this applies to you.

Is it hard to open your Mouth?

Does it hurt to chew, bite or swallow?

Do your gums bleed when you brush or floss your teeth?

Have you ever had periodontal (gum) treatments like scaling and root planing?

Do you have, or have you ever had, any sores or growths in your mouth?

Do you clench or grind your teeth?

Does your jaw click, pop or hurt?

Do you have earaches or neck pains?

Does dental treatment make you nervous?

Have you ever experienced any of these sleep-related breathing disorders?

Mouth breathing

Snoring

Trouble breathing during sleep

Have you ever had a serious injury to your head or mouth?

if yes, please describe what happened and when it happened

Are you unhappy with your smile currently?

Yes

If yes, why? please mark all that apply:

The color of your teeth

The shape of your teeth

The position of your teeth

Other, please describe

If other, Please describe

MEDICATIONS & OTHER PRODUCTS/SUBSTANCES

If yes, what medication are you taking?

Some commonly-prescribed drugs include denosumab (Xgeva®), pamidronate (Aredia®) or zolendronate (Zometa®).

If yes, what medication are you taking?

How many years have you been taking it?

How many alcoholic beverages do you have per week?

If yes, what substance?

If yes, for what reason?

If yes, please list them here and include information about how much and how often you use each one.

Women Only: Are you:

If yes, No. of Weeks

Please describe any yes answer and include information about your experience.

MEDICAL & SURGICAL HISTORY

Date of last physical exam:

What is your normal blood pressure (systolic, diastolic)?

Doctor's Name

Phone No.

If you answered yes to any of the above, please explain.

MEDICAL HISTORY SPECIFIC

Please use an “X” to mark your answers to the following questions

Breathing (Respiratory) Health

Asthma (COPD)

Bronchitis

Emphysema

Sinus trouble

Tuberculosis

Other

Cancer

Type

Date of Diagnosis

Chemotherapy

Radiation Treatment

Blood (Circulatory) Health

Anemia

Blood transfusion

Hemophilia

High or low blood pressure

If (Blood transfusion is check), please indicate date

Brain (Neurological) Mental Health

Anxiety

Depression

Epilepsy

Mental health disorders

Neurological disorders

Post-traumatic stress disorder

Traumatic brain injury or concussion

Other

Autoimmune Disease

AIDS or HIV Infection

Lupus

Eye (Vision)Health

Glaucoma

Digestive Health

Gastrointestinal disease

G.E. reflux/persistent heartburn (GERD)

Stomach ulcers

Do you have any disease, condition, or problem that's not listed here? if so, please explain.

MEDICAL SYMPTOMS/GENERAL

In the past 30 days, have you

had pan or tightness in the chest coughed up blood or had a cough that lasted longer than 3 weeks?

Been exposed to anyone with tuberculosis?

Had a rapid or irregular heart beat?

Found it hard to catch your breath?

Had a high fever (greater than 101.5f) for no reason?

Noticed a change in your vision?

Fainted for no reason?

Experienced vomiting, diarrhea, chills night sweats or bleeding?

Had migraines or severe headaches?

NOTE: It’s important for both the doctor and patient to talk honestly about the patient's health before dental treatment starts.I have answered the above questions completely, accurately and to the best of my ability.

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.

Signature of Patient/Legal Guardian

Date

Office Use Only

Comments

Medical Alert

Premedication

Allergies

Anesthesia

Reviewed by

Date

Your information will be encrypted.