MEDICAL HISTORY

MEDICAL HISTORY
Patient Name:

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date

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

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship:
Are you currently under the care of a physician for any illness or health problem?
Date of last visit:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for last visit:
Physician 1:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Specialty:
Physician 2:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Specialty:
Are you required to take any antibiotics prior to treatment:
Do you have any allergies or adverse side effects to any medications? If “YES” Please Explain:

Yes
Please list any medications you are currently taking and for what reasons:
Type Here Type Here Type Here Type Here Type Here Type Here

Do you have, or have you had any of the following health conditions? (Please provide information to all YES answers):

Rows	YES	NO
Rheumatic Fever, Scarlet Fever, Rheumatic or Congenital Heart Disease, Heart Murmur, Mitral- Valve Prolapse
Heart Trouble, Heart Attack, Angina, Pacemaker
Artificial Limb/Joint, Heart Valve
Stroke, Fainting Spells, Seizures/
High/Low Blood Pressure
Respiratory Lung Disorders, Tuberculosis, Asthma, Emphysema, Etc
Diabetes (self or family history)
Restricted Diet of ANY kind
Cancer, Tumors
Kidney Trouble
Hepatitis, Jaundice, Liver Disease
Stomach/Intestinal Problems
Arthritis/Rheumatism
Glaucoma/Cataracts
Excessive Bleeding, Bruising or Anemia
Cold Sores, Herpes, Syphilis or Gonorrhea
HIV/AIDS/AIDS Related Complex
Psychiatric Care
Do you have a history of drug or alcohol abuse?
Do you smoke?
If you are a woman, are you pregnant or planning pregnancy?
Does your health restrict your physical activity in any way?
Are you taking ANY medications, prescriptions, and/or over-the-counter, (Including Fosamax, Aspirin, vitamins, Meridia, hormones, birth control pills, diet pills?
Have you ever taken Fen-Phen?
Do you have any disease/condition/handicap not listed above?

To assist us with your dental needs/concerns, please answer the following questions.

Rows	YES	NO
Are any of your teeth sensitive to heat, cold or pressure?
Do any of your teeth ache?
Do you grind your teeth or clench your jaw?
Do you have a clicking in the jaw joint or around your ear?
Do you have difficulty opening your mouth wide?
Have you ever had braces (orthodontics)? If “yes” how long ago?
Do you have difficulty swallowing or dry mouth?
Are there any sores or growths in your mouth?
Are you dissatisfied with the appearance of your teeth?

Do you have any other dental concerns?
*Please note, a change in your health status should be reported to the office at the earliest possible time*

The following information is essential for this office to provide dental care in a manner that is compatible with your general health. Thank you for taking the time to fill out this form completely and accurately. Incorrect information can be dangerous to your health. Your complete comfort and satisfaction are our primary concern. To the best of my knowledge, the foregoing questions have been accurately answered. I grant the right to Dr. Binon’s office to release health information obtained from me, and information about my dental treatment to third party payors and/or other health practitioners.
Print Name

First NameLast Name
Is patient a minor?
Patient (or guardian) Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: