• Dental and Medical History

  • Date
     - -
  • Primary reason for this dental appointment

  • Dental History

  • Do you have a specific dental problem?
  • Do you have dental examinations on a routine basis?
  • Do you think you have active decay or gum disease?
  • Do you brush and floss on a routine basis?
  • Do your gums ever bleed?
  • Do you like your smile?
  • Does food catch between your teeth?
  • Do you want to keep your remaining teeth?
  • Have your past experiences in a dental office always been positive?
  • Do you smoke or chew? Any sores or growths in your mouth?
  • Date of last full mouth x-rays (16 small films or panoramic):
     - -

  • Medical History

  • Are you under a physician's care now?
  • Format: (000) 000-0000.
  • Have you ever been hospitalized or had a major operation?
  • Have you ever had a serious injury to your head or neck?
  • Are you taking any medications, aspirin, vitamins, herbals, pills or drugs?
  • Are you on a special diet?
  • Are you allergic to any medications or substances?
  • Please check box below
  • Women (Please check):
  • Do you now have or have you ever had any of the following? Please check appropriate boxes. 'If yes to any of the starred conditions, please call prior to your appointment .. premedication or changes In medication may be required.
  • Have you ever had any other serious illness not checked above?
  • Do you wish to talk to the dentist privately about any problem?

  • To the best of my knowledge, all the preceding answers are correct. If I have any changes in my health status or if my medicines change, I shall inform Ihe dentist and staff at the next appointment without fail.

  • Date
     - -
  • Date
     - -

  • Medical Updates

  • I have read my MEDICAL HISTORY dated  and confirm that it adequately states past and present conditions.

  • Rows
  • Should be Empty: