Medical and Dental History

Medical History

Name

In the event of an emergency, whom should we contact?

Emergency Contact Name

Phone

Relationship

Name of Physician

Phone

ARE YOU CURRENTLY TAKING ANY MEDICATIONS?

Yes No

For what purpose?

Medications

ARE YOU TAKING ANY BLOOD THINNERS? (Coumadin, Warfarin, aspirin, etc.)

Yes No

Which one?

HAVE YOU EVER TAKEN ANY MEDICATION FOR OSTEOPOROSIS?

Yes No

HAVE YOU HAD ANY OF THE FOLLOWING?

Joint/Bone Replacement

Yes No

Ulcers/Colitis

Yes No

Mitral Valve Prolapse

Yes No

Tuberculosis

Yes No

Heart Murmur

Yes No

Diabetes

Yes No

Rheumatic/Scarlet Fever

Yes No

Jaundice

Yes No

Pacemaker/Heart Surgery

Yes No

Hepatitis

Yes No

Heart Disease

Yes No

Emphysema

Yes No

High/Low Blood Pressure

Yes No

Asthma/Hay fever

Yes No

Epilepsy/Fainting Spells

Yes No

Sinus Trouble

Yes No

Arthritis

Yes No

Stroke

Yes No

Venereal Disease

Yes No

Glaucoma

Yes No

HIV+/AIDS

Yes No

Cancer/Chemo

Yes No

TMJ/Jaw Pain

Yes No

Abnormal Bleeding

Yes No

Snoring/Sleep Apnea

Yes No

Anemia

Yes No

PLEASE LIST ANY SERIOUS MEDICAL CONDITIONS THAT YOU HAVE EVER HAD

ARE YOU ALLERGIC TO:

Penicillin

Codeine

Aspirin

Local Anesthetic

Latex

OTHER ALLERGIES:

Women

Are you pregnant?

Yes No

Nursing?

Yes No

Birth Control Pills?

Yes No

Dental History

Do you need to take antibiotics before dental treatment?

Yes No

Do your gums ever bleed?

Yes No

Are you currently in pain?

Yes No

Have you ever had problems associated with previous dental work?

Yes No

Do you now or have you ever experienced pain / discomfort in your jaw joints (TMJ/ TMD)?

Yes No

Do you clench or grind your teeth?

Yes No

Does your jaw ever pop or click?

Yes No

Do you get frequent headaches?

Yes No

Your current dental health is:

Good Fair Poor

How many times a day do you brush?

How many times a week do you floss?

Have you ever been diagnosed with or treated for periodontal disease?

Yes No

Are your teeth sensitive to hot, cold, sweets, biting or touch?

Yes No

Do you have dry mouth?

Yes No

Do you like your smile?

Yes No

Would you like whiter teeth?

Yes No

Fresher Breath?

Yes No

Do you now or have you ever smoked or used tobacco in any form?

Yes No

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Signature

Date

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