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 Name
Middle Name
Last Name
Gender
*
Please Select
Male
Female
Previous Dentist
Telephone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of last dental visit
-
Month
-
Day
Year
Date
Date of last x-rays
-
Month
-
Day
Year
Date
Check all that apply
Bad breath
Bleeding gums
TMJ pain
Gum disease
Gag reflex
Broken fillings
Sensitive to sweets
Grind/clench teeth
Loose teeth
Sensitive to biting/chewing
Sensitive to hot/cold
Food packing between teeth
Bad dental experience in past
None
Do you smoke or use any tobacco products?
*
Yes
No
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
-
Month
-
Day
Year
Date
Currently under doctor’s care?
Yes
No
Why?
Are you pregnant?
Yes
No
Due Date
-
Month
-
Day
Year
Date
Do you take birth control?
Yes
No
Do you have panic attacks?
Yes
No
Are you allergic to: (check all that apply)
Penicillin
Sulfa Drugs
Codeine
Aspirin
Iodine
Latex
Other
If "Other" Please Explain
List current medications
Have you had prosthetic joint replacement surgery?
Do you snore?
Yes
No
Have you been diagnosed with sleep apnea?
Yes
No
Do you have or have you had any of the following: (Check all that apply)
AIDS/HIV+
Anaphylaxis
Arthritis
Epilepsy
Food allergy
Heart murmur
Psychiatric care
Cancer
Tonsillitis
Chemotherapy
Emphysema
Cough up blood
Diabetes
Kidney disease
Blood disease
Thyroid disease
Nervous problems
Heart problems
Tuberculosis
Radiation therapy
Persistent cough
High blood pressure
Jaw pain
Liver disease
Metal allergy
Back problems
Herpes
Respiratory disease
Drug use
Hepatitis/Jaundice
Low blood pressure
Shortness of breath
Rheumatic fever
Artificial heart valve
Mitral valve prolapse
Rapid weight loss/gain
Circulatory problems
Swelling of feet/ankles
Shingles
Anemia
Skin rash
Stroke
Headaches
Pacemaker
Ulcer
Hemophilia
Colitis
Other
If "Other" Please Explain
Signature
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
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