PATIENT DENTAL & MEDICAL HEALTH HISTORY

Today's Date

Patient name (first and last)

DOB

Current Address

City

State

Zip

Home Phone

Work Phone

Cell Phone

Preferred Methods of Contact

Call

Text

Emergency Contact (Name and Number)

Are you under the care of a physician at the present time?

Yes No

If so, what is the condition being treated?

Primary Care Physician & Contact Information

Preferred Pharmacy

Pharmacy Phone Number

Do you have dental insurance coverage?

Yes No

Insurance Provider

Insurance Group # or member ID # if provided

Dental Health

Are you having any pain or discomfort at this time?

Yes No

Do your gums bleed while brushing and flossing?

Yes No

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

Yes No

Have you ever experienced any of the following problems with your jaw?

Yes No

(Check all that apply)

clicking

pain

difficulty in opening and closing

difficulty in chewing

Do you have frequent headaches?

Yes No

Do you clench or grind your teeth?

Yes No

If yes, when?

Have you ever had any orthodontic treatment?

Yes No

If so, do you wear a retainer?

Have you ever had any type of trauma to your mouth, jaw, or face?

Yes No

If yes, describe.

Do you wear dentures or partials?

Yes No

If so, date of placement.

Do you have any concerns about bad breath odor?

Yes No

Are you pleased with the appearance and color of your teeth when you smile?

Yes No

Medical Health

Other antibiotics

Other

Have you been hospitalized during the past two years?

Yes No

Have you been asked by your medical doctor to premedicate before any dental treatment?

Yes No

If yes, what premedication was prescribed?

Do you smoke, chew, or vape nicotine/tobacco?

Yes No

If yes, how often?

Do you smoke, ingest, or vape marijuana?

Yes No

If yes, how often?

Do you drink alcohol?

Yes No

If yes, how often and in what quantity?

Other

Major surgeries (type and year)

Please list all medications you are currently taking, including prescription drugs, over-the-counter drugs, vitamins, herbal remedies, and supplements.

Add new row

Are you pregnant now?

Yes No

Are you nursing?

Yes No

Do you have a history of miscarriages?

Yes No

Do you take any hormones or birth control pills?

Authorization: I have reviewed the information on this form, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.

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 Signature

Date

Guardian Signature

Patient Review and Update of Form: please review this form annually, note any changes, sign and date in the spaces below:

Revision Signature

Date

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