Patient Medical History

Patient's Name

Date of birth

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body, health problems that may have, or medication that you may be taking, could have an important interrelation with the dentistry that you will be receiving. Thank you for answering the following questions.

1. Are you in good health

Yes No

2. Have there been any changes in your general health within the past year

Yes No

3. Date of your last physical exam

4. Physician's Name

Address

Phone no.

5. Are you under the care of a physician

Yes No

6. Have you ever been hospitalized for any surgical operation or serious illness?

Yes No

Please explain:

7. Are you taking Medicine(s) including non-prescription medicine

Yes No

If yes, What medicine(s) are you taking

8. Have you had any abnormal bleeding

Yes No

9. Do you bruise easily

Yes No

10. Have you ever required a blood transfusion

Yes No

11. Have you had a recent weight loss

Yes No

12. Have you ever taken Fen-Phen or Redux

Yes No

13. Do you use tobaco

Yes No

14. Do you or have you used controlled substance

Yes No

15. Are you wearing contact lenses?

Yes No

16. Do you have any disease, condition or problem not listed above that you think I should know about

Yes No

Women only:

Are you pregnant or think you may be pregnant?

Yes No

Are you nursing?

Yes No

Are you taking birth control pills

Yes No

Are you allergic to or have you had reactions to:

Local anesthetics like novocaine

Yes No

Penicillin or other antibiotics

Yes No

Sulfa drugs

Yes No

Barbiturates, Sedatives or Sleeping pills

Yes No

Aspirin

Yes No

Iodine

Yes No

Any metals (E.G., Nickel, Mercury, etc.)

Yes No

Latex/Rubber

Yes No

Other (Please List)

Do you have or have you ever had the following:

Rheumatic heart disease or rheumatic fever

Yes No

Scarlet fever

Yes No

Heart defect or heart murmur

Yes No

Heart trouble, Heart attack, or Angina

Yes No

Chest pain

Yes No

Shortness of breath

Yes No

Pacemaker

Yes No

Heart surgery

Yes No

High/low blood pressure

Yes No

Congenital heart problem

Yes No

Swelling of feet, Ankles, Hands

Yes No

Hepatitis, Jaundice or Liver Disease

Yes No

Stroke

Yes No

Sinus trouble

Yes No

Lung or breathing problems

Yes No

Asthma or hay fever

Yes No

Hives or skin rash

Yes No

Fainting or dizzy spells

Yes No

Diabetes

Yes No

Aids or HIV infection

Yes No

Thyroid problems

Yes No

Allergies

Yes No

Arthritis or Rheumatism

Yes No

Joint replacement or implant

Yes No

Stomach ulcer

Yes No

Kidney trouble

Yes No

Tuberculosis

Yes No

Persistent cough

Yes No

Couch that produces blood

Yes No

Chemotherapy (cancer, leukemia)

Yes No

Sexually transmitted disease

Yes No

Epilepsy or Seizures

Yes No

Anemia

Yes No

Glaucoma

Yes No

Nervousness

Yes No

Tonsillitis

Yes No

Tumors

Yes No

Mental health care

Yes No

Back problems

Yes No

Chemical dependency

Yes No

Mitral valve prolapse

Yes No

Cortisone treatment

Yes No

Cold sores/fever blisters

Yes No

Hypoglycemia

Yes No

Eating disorders

Yes No

Patient Dental History

Patient's Name

Date of Birth

Reason for this visit

When was your last dental visit

What was done then

How often did you visit the dentist before then

Previous Dentist (Name and Location)

Have you had a complete series of dental films (X, Rays) taken When Where

How often do you brush your teeth

How often do you floss your teeth

Is your drinking water fluoridated

Do your gums bleed while brushing or flossing

Yes No

Are your teeth sensitive to hot or cold liquids/foods

Yes No

Are your teeth sensitive to sweet or sour liquids/foods

Yes No

Do you feel pain to any of your teeth

Yes No

Do you have any sores or lumps in or near your mouth

Yes No

Have you had any head, neck or jaw injuries

Yes No

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

Clicking

Yes No

Pain (joint, ear, side of face)

Yes No

Difficulty in opening or closing

Yes No

Difficulty in chewing

Yes No

Do you have frequent headaches

Yes No

Do you clench or grind your teeth

Yes No

Do you bite your lips or cheeks frequently

Yes No

Have you noticed any loosening of your teeth

Yes No

Does food tend to become caught between your teeth

Yes No

Have you ever had periodontal treatment (gums)

Yes No

Ever worn a bite plate or other appliance

Yes No

Have you ever had any difficult extractions in the past

Yes No

Have you ever had any prolonged bleeding following extractions

Yes No

Do you wear dentures or partials

Yes No

If yes, date of placement

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

Yes No

If you could change anything about your smile, what would you chance?

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period such dental care to third party and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for service. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

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 or Parent if Minor

Date

Doctor's Comments

Signature

Date

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