The Family Dental Center
Patient Name
Today's Date
-
Month
-
Day
Year
Date
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Occupation
Social Security Number
Email
example@example.com
Cell Number
Please enter a valid phone number.
Format: (000) 000-0000.
Dental History
Reason For Today's Visit
Date of Last Dental Exam and Cleaning
-
Month
-
Day
Year
Date
Please Select Any Conditions That Apply:
Bad Breath
Bleeding Gums
Food Collection Between Teeth
Sores or Growths in Your Mouth
Loose Teeth or Broken Fillings
Periodontal Treatment
Sensitively to Cold
Sensitively to Hot
Sensitively to Sweets
Sensitivity When Biting
Grinding Teeth
Clicking or Popping Jaw
How Often Do You Floss?
How Often Do You Brush?
Patient Medical History
Physician
Office Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Last Exam
-
Month
-
Day
Year
Date
Are You Under Medical Treatment Now?
Yes
No
If Yes, What For?
Have You Ever Been Hospitalized For Any Surgical Operation Or Serious Illness?
Yes
No
If Yes, What For?
Please List Medications You Are Currently Taking Including Vitamins and Herbal Supplements.
Please Select All Drug Allergies
Aspirin
Sulfa
Barbiturates
Latex
Codeine
Local Anesthetic
Penicillin
Other
IN ORDER TO SERVE YOU BETTER DURING ORAL CANCER SCREENINGS, PLEASE ANSWER THE FOLLOWING:
Do You Use Nicotine Products In The Form Of Vaping Or E-Cigarettes?
Yes
No
Do You Use Tobacco?
Yes
No
Do You Drink Alcohol?
Yes
No
Do You Use Cocaine or Other Drugs?
Yes
No
Have You Ever Taken Any Of The Group Of Drugs Collectively Referred To As Bisphosphonates? (This Would Include Drugs For Osteoporosis Such As Samax, Boniva, Actonel, Atelvia, And Reclast)
Yes
No
Do You Take Any Blood Thinners> Including Daily Aspirin?
Yes
No
Please Select If You Have Or Have Had Any Of The Following:
High Blood Pressure
Stroke
Radiation Therapy
Aids or HIV Infection
Heart Attack
Low Blood Pressure
Blood Disease
Thyroid Problem
Artificial Heart Valves
Emphysema/COPD
Chemotherapy
Arthritis
Diabetes Type 1 Or Type 2
Hay Fever/Allergies
Leukemia
Joint Replacement/Implant
Heart Disease
Tuberculosis
Steroid Treatment
Stomach Trouble/Ulcers
Cardiac Pacemaker
Persistent Cough
Kidney Disease
Glaucoma
Heart Murmur
Asthma
Liver Disease
Cataracts
Angina
Anemia
Hepatitis/Jaundice
Epilepsy/Seizures
Chest Pains
Cancer
Sexually Transmitted Disease
Autism/Spectrum Disorders
Other
Women Only:
Are You Pregnant, Or Do You Think You May Be Pregnant?
Yes
No
Are You Nursing?
Yes
No
Are You Taking Birth Control?
Yes
No
Signature
Patient, Parent, or Guardian
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: