Medical & Dental History

Step 1 of 6 - Patient Information

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Patient Information

Patient's Name*

First Last

Patient Date of Birth*

Month

Day

Year

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Patient's Number

Medical Information

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

Thank you for answering the following questions.

Are you in good health?*

Yes

Have there been any changes in your general health within the past year?*

Yes

Date of your last exam:*

MM slash DD slash YYYY

Physician's Name*

Address*

Phone*

Are you now under the care of a physician?*

Yes

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

Yes

Please explain:*

Have you had any abnormal bleeding?*

Yes

Are you taking any medicine(s) including non-prescription medicine?*

Yes

Please list medicine(s) you are taking:*

Do you bruise easily?*

Yes

Have you ever required a blood transfusion?*

Yes

Have you had a recent weight loss?*

Yes

Have you ever taken fen-phen/redux?*

Yes

Have you ever taken fosamax, boniva, actonel?*

Yes

Or any cancer medications containing bisphosphonates.

Have you taken viagra, revatio, cialis or levitra in the last 24 hours?*

Yes

Do you use tobacco?*

Yes

Do you or have you used controlled substances?*

Yes

Do you wear contact lenses?*

Yes

Do you have a persistent cough or throat clearing not associated with a known illness, lasting more than 3 weeks?*

Yes

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

Yes

Other:*

Are you allergic to or have you had reactions to:

Local anesthetics like novocaine?*

Yes

Penicillin or other antibiotics*

Yes

Sulfa drugs*

Yes

Barbiturates, sedatives or sleeping pills*

Yes

Aspirin*

Yes

Iodine*

Yes

Any metals (e.g. nickel, mercury, etc.)*

Yes

Latex/rubber*

Yes

List any other allergens not mentioned:

Do you have or have you ever had the following:

Rheumatic heart disease or rheumatic fever*

Yes

Scarlet fever*

Yes

Heart defect or heart murmur*

Yes

Heart trouble, heart attack, or angina*

Yes

Chest pain*

Yes

Shortness of breath*

Yes

Pacemaker*

Yes

Heart surgery*

Yes

High/low blood pressure*

Yes

Congenital heart problem*

Yes

Swelling of feet, ankles, hands*

Yes

Hepatitis, jaundice or liver disease*

Yes

Stroke*

Yes

Sinus trouble*

Yes

Lung or breathing problems*

Yes

Asthma or hay fever*

Yes

Hives or skin rash*

Yes

Fainting or dizzy spells*

Yes

Diabetes*

Yes

AIDS or HIV infection*

Yes

Thyroid problems*

Yes

Allergies*

Yes

Arthritis or rheumatism*

Yes

Joint replacement or implant*

Yes

Stomach ulcer*

Yes

Kidney trouble*

Yes

Tuberculosis*

Yes

Persistent cough*

Yes

Cough that produces blood*

Yes

Chemotherapy (cancer, leukemia)*

Yes

Sexually transmitted disease*

Yes

Epilepsy or seizures*

Yes

Anemia*

Yes

Glaucoma*

Yes

Nervousness*

Yes

Tonsilitis*

Yes

Tumors*

Yes

Mental health care*

Yes

Back problems*

Yes

Chemical dependency*

Yes

Mitral valve prolapse*

Yes

Cortisone treatment*

Yes

Cold sores/fever blisters*

Yes

Hypoglycemia*

Yes

Eating disorders*

Yes

Dental History

Reason for this visit:*

When was your last dental visit?*

Month

Day

Year

What was done?*

How often did you visit the dentist before then?*

Previous Dentist Name

Previous Dentist Location

Have you had a complete series of dental films (x-rays)?*

When?*

Month

Day

Year

Where?*

How often do you brush your teeth?*

How often do you floss your teeth?*

Is your drinking water fluoridated?*

Yes

Do your gums bleed while brushing or flossing?*

Yes

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

Yes

Are you teeth sensitive to sweet or sour liquids/foods?*

Yes

Do you feel pain to any of your teeth?*

Yes

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

Yes

Have you had any head, neck or jaw injuries?*

Yes

Do you bite your lips or cheeks frequently?*

Yes

Have you noticed any loosening or your teeth?*

Yes

Does food tend to become caught between your teeth?*

Yes

Have you ever had periodontal treatment (gums)?*

Yes

Ever worn a bite plate or other appliance?*

Yes

Have you ever had any difficult extractions in the past?*

Yes

Have you ever had any prolonged bleeding following extractions?*

Yes

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

Yes

Do you wear dentures or partials?*

Yes

Date of Placement*

Month

Day

Year

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

Clicking*

Yes

Pain (joint, ear, side of face)*

Yes

Difficulty in opening or closing*

Yes

Difficulty in chewing*

Yes

If you could change ANYTHING about your smile, what would you change?*

Authorization and Release

A&R*

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 my or my child during the period of such dental care to third party payors 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 services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.*

Signature of Patient (or Parent/Guardian if Minor)*

Date*

Month

Day

Year

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Doctor's Comments

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Doctor's Signature

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Date

MM slash DD slash YYYY

Medical & Dental History

Patient Information

Medical Information

Are you allergic to or have you had reactions to:

Do you have or have you ever had the following:

Dental History

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

Authorization and Release

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