www.smileoasis.com - Dental and Medical History

Dental and Medical History

Please note that it is important to fill in all the fields before submitting. Thank you.
DENTAL HISTORY
Patient Name *

First NameMiddle NameLast Name
Gender*
Previous Dentist
Telephone *
Please enter a valid phone number.Format: (000) 000-0000.
Date of last dental visit

MonthDayYear
Date
Date of last x-rays

MonthDayYear
Date
Check all that apply
Bad breathBleeding gumsTMJ painGum diseaseGag reflexBroken fillingsSensitive to sweetsGrind/clench teethLoose teethSensitive to biting/chewingSensitive to hot/coldFood packing between teethBad dental experience in pastNone
YesNo
What and how often?
How often do you brush?
How often do you floss?
If you could change anything about your smile, what would it be?
Other information about your dental health
MEDICAL HISTORY
Physician
Date of last exam

MonthDayYear
Date
YesNo
Why?
YesNo
Due Date

MonthDayYear
Date
YesNo
YesNo
PenicillinSulfa DrugsCodeineAspirinIodineLatexOther
If "Other" Please Explain
List current medications
Have you had prosthetic joint replacement surgery?
YesNo
YesNo
AIDS/HIV+AnaphylaxisArthritisEpilepsyFood allergyHeart murmurPsychiatric careCancerTonsillitisChemotherapyEmphysemaCough up bloodDiabetesKidney diseaseBlood diseaseThyroid diseaseNervous problemsHeart problemsTuberculosisRadiation therapyPersistent coughHigh blood pressureJaw painLiver diseaseMetal allergyBack problemsHerpesRespiratory diseaseDrug useHepatitis/JaundiceLow blood pressureShortness of breathRheumatic feverArtificial heart valveMitral valve prolapseRapid weight loss/gainCirculatory problemsSwelling of feet/anklesShinglesAnemiaSkin rashStrokeHeadachesPacemakerUlcerHemophiliaColitisOther
If "Other" Please Explain
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Dental and Medical History

DENTAL HISTORY

Check all that apply

MEDICAL HISTORY