Dental/Medical History

Patient Name

Date of Birth

Physician's name

Physician's phone number

Date of last physical exam

Are you currently receiving medical treatment?

Yes No

If Yes, please explain

Are you taking any medications, over the counter medications or herbal supplements?

Yes No

If Yes, please list them

Are you allergic to any medications (e.g. codeine, penicillin, sulfa, etc.)?

Yes No

If Yes, please list them

Are you allergic to any metals in jewelry (nickel or others) or to Latex?

Yes No

If Yes, please list them

Do you use tobacco products of any kind? (including vape)

Yes No

If yes, what type? How often?

Women:

Are you pregnant?

Yes No

Are you nursing?

Yes No

Are you using hormonal birth control?

Yes No

If Hepatitis, please specify type

Please describe any past or current medical condition that may possibly affect your dental treatment

How long has it been since your last dental visit?

What was this for?

Are you having any problems now?

Reason for this visit?

Date of last dental x-rays?

Have you had local anesthetics (Novocaine) for dental work?

Yes No

Any issues with anesthetics?

Yes No

Do you have dentures?

Yes No

Do they fit well?

Yes No

Do you have any growths or sore spots in your mouth?

Yes No

Do your gums bleed?

Yes No

Do you have any pain in your jaw joints or near your ears?

Yes No

Is any part of your mouth sensitive to cold, hot, sweets, or pressure?

Yes No

If yes, where?

Does it hurt to chew on any part of your mouth?

Yes No

If yes, where?

Would you like to learn more about proper dental care and preventative care?

Yes No

Are you nervous about receiving care?

Yes No

Please state any concerns you have about your dental care

I hereby certify that I have answered all questions on this form truthfully and, to the best of my knowledge, have not omitted anything. I also certify that I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.

Patient/Guardian Signature

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Dental/Medical History

Mann Family Dental Care, LLC