Name
*
First Name
Last Name
Date of birth (DD/MM/YY):
/
Month
/
Day
Year
Date
Physician's Name
Are you presently under a Physicians care? If yes, for what condition:
What drugs/medication are you currently taking, including Aspirin:
Have you ever been hospitalized? If yes, for what condition?
Do you have any Drug, LATEX or Food allergies or reactions? Do you have or have you had any of the following:
MEDICAL HISTORY
Please answer "YES" or "NO" to all.
Hepatitis, jaundice, liver disease
YES
NO
Rheumatic fever
YES
NO
Heart Murmur
YES
NO
Heart Trouble
YES
NO
High or low blood pressure
YES
NO
Chest pain or shortness of breath
YES
NO
Asthma, hayfever, sinus problems
YES
NO
Diabetes
NO
Type I
Type II
If diabetic; HbA1c levels
Epilepsy or Seizures
YES
NO
Arthritis or Rheumatism
YES
NO
Stomach Problems or Ulcers
YES
NO
Kidney disease
YES
NO
Sexually transmitted infection:
YES
NO
If YES, please specify:
.
HIV /are you at risk for HIV
YES
NO
Hearing Problems
YES
NO
Glaucoma
YES
NO
Taken IV or ORAL Bisphosphonates
YES
NO
Medical Radiation (Cancer) Treatments
YES
NO
Abnormal bleeding problems
YES
NO
Take ASA daily
YES
NO
Clotting Problems
YES
NO
Other blood concerns/problems
YES
NO
Are you a nervous patient
YES
NO
Have you had any other serious illnesses
YES
NO
Do you smoke? Vape? Or use chewing Tabaco products?
YES
NO
If so, how often and for how many years have you used Tabaco products?
Cancer
YES
NO
Do you have sleep apnea
YES
NO
Are you Pregnant? if Yes, how many weeks?
YES
NO
Other
Do you take birth control pills *Please note Antibiotics can cause disruption to the effectiveness of your birth control pills*
YES
NO
Are you post menopause
YES
NO
DENTAL HISTORY
Please answer "YES" or "NO" to all.
Had any injury to your face or jaw?
YES
NO
Had any pain in your face or jaw?
YES
NO
Had bleeding gums?
YES
NO
Had loose teeth?
YES
NO
Had bad breath?
YES
NO
Had freezing with your cleanings?
YES
NO
Seen the Hygienist?
YES
NO
Have you seen a Hygienist?
YES
NO
How often?
3 month intervals
4 month intervals
6 month intervals
When was your last dental hygiene visit?
-
Month
-
Day
Year
Date
Had gum surgery?
YES
NO
Had sore or sensitive teeth?
YES
NO
How many times a day do you brush?
0
1
2
3
Do you use...
Soft bristle tooth brush
Medium bristle tooth brush
Hard bristle tooth brush
Do you use dental aids such as...
Floss
Toothpicks
Mouthwash
Had your teeth straightened?
YES
NO
Do you clench or grind your teeth?
YES
NO
If Yes, do you have a nightguard?
YES
NO
Date:
/
Month
/
Day
Year
Date
Signature of Patient
*
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