Dental & Medical History

Dental & Medical History
Patient Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Passport Number:
Country Issued:
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email
example@example.com

Dental Questionnaire

Rows	Yes	No
Do you get food caught between your teeth?
Do you have any missing teeth?
Do your gums bleed?
Do you have areas of receded gums?
Do you floss regularly?
Does gum disease run in your family?
Are your teeth hot/cold sensitive?
Teeth extracted?
Are your teeth sensitive to sweets?
Do you clench or grind your teeth?
Do you have a night guard/bite splint?
Have you ever had an oral surgery?
Do you have tired jaws?
Do you have orthodontics/braces?
Do you have popping or clicking in the jaw?
Have you ever had a periodontal treatment?
Do you chew on pens, fingernails, etc?
Have you had any injury to your face/jaw?
Do you drink coffee, tea or red wine?

Previous Dentist Name

First NameLast Name
Dentist's Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Dentist's Email:
example@example.com
Last Visit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last Cleaning

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you have any dental problems now? If yes, please describe:

Medical Questionnaire

Rows	Yes	No
Heart surgery, disease, attack?
Blood transfusion?
Heart murmur?
Hemophilia or blood disorder?
Mitral valve prolapse?
Hepatitis A, B?
Heart attack or strokes?
Tuberculosis or lung disease?
Artificial Heart Valve/ Pacemaker?
Tumors?
Heart pacemaker?
Headaches or migraines?
Artificial joints (hip, knee, etc)?
Convulsions or epilepsy?
Neurological disorders?
Dizzy spells or fainting?
Rheumatic fever?
Cold sores or fever blisters?
Diabetes?
Thyroid disorder?
Kidney disease?
Stomach, intestinal, or colon disorders?
Jaundice or liver disease?
Cortisone or steroid therapy?
High blood pressure?
Possess the HIV or AIDS antibody?
Low blood pressure?
Psychiatric or psychological care?
Cancer?
Hay fever or airborne allergies?
Radiation or Chemotherapy?
Bruise easily?
Emphysema or asthma?
Venereal disease?
Alcoholism?

Do you have any other disease/condition not listed above?
Height (feet/inches):
in Feet/Inches
Weight (lbs):
Do you use recreational drugs?
How often do you consume alcoholic beverages?
Do you or have you ever smoked or used tobacco? Please describe type, frequency and duration.
Are you currently pregnant or trying to become pregnant?
Are you currently breastfeeding?
Are you currently using a prescription type contraceptive? Please explain
Do you have allergies?
If yes, what allergies?
Have you had any medical care within the past two years? If yes, please specify the type of care and why:
Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosages of aspirin? This includes blood thinners. If yes, please list:
Have you ever taken prescription medications for weight loss (diet pills)? If yes, what?
Are you aware of having an allergic (or adverse) reaction to any substance or medication? If yes, please specify:
Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or other similar drugs?
Have you been a patient in the hospital during the past five years?
Have you ever smoked or used tobacco products?
Have you ever served in the military?
If yes, when did you quit?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I, the above-named patient, understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Dental care has my permission to ask the respective health care provider or agency, who may release such information. I will notify this dental care facility of any and all changes in my health or medications. I consent to the performing of dental procedures agreed to be necessary or advisable, including the use of local anesthetics.Signature Date
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