• Patient Dental & Medical Health History Information

  • To our patients: Please know that we may ask follow-up questions to make sure we have all of the information we need in order to treat you.

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  • PATIENT INFORMATION

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Date of Birth:
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  • Emergency Contact:

  • Format: (000) 000-0000.

  • If executing this form as the patient’s personal representative, I represent and warrant that I have full legal right and authority to consent to the performance of any procedure(s) on this patient. If for any reason I no longer have such legal right and authority, I will immediately notify the practice in writing.

  • DENTAL HISTORY & SYMPTOMS

  • Are you currently experiencing any dental pain or discomfort?

  • When was your last dental exam?
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  • Please check the box ONLY if this applies to you.
  • Have you ever experienced any of these sleep-related breathing disorders? Mouth breathing, Snoring, Trouble breathing during sleep
  • Which sleep-related breathing disorders have you experienced?
  • Have you ever had a serious injury to your head or mouth?
  • Have you ever had problems with dental treatment in the past?
  • Have you ever had a reaction to, or problem with, dental anesthesia?
  • Are you unhappy with your smile?
  • If yes, why? Please mark all that apply:

  • MEDICATIONS & OTHER PRODUCTS/SUBSTANCES

  • Are you taking any blood thinners (such as Coumadin, Warfarin, rivaroxaban (Xarelto®), dabigatran (Pradaxa®), clopidogrel (Plavix®), heparin or aspirin)?
  • Are you taking any medication to treat osteoporosis or Paget’s disease? Some commonly-prescribed drugs include alendronate (Fosamax®), risedronate (Actonel®), ibandronate (Boniva®), zolendronate (Reclast®), and denosumab (Prolia®).
  • Are you taking, or scheduled to take, an IV medication to treat bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer? Some commonly-prescribed drugs include denosumab (Xgeva®), pamidronate (Aredia®) or zolendronate (Zometa®).
  • Are you taking hormonal replacements?
  • Do you use any form of tobacco or nicotine products (cigarettes, cigars, snuff, chew, bidis)?
  • Do you use vaping products?
  • Do you use controlled substances (drugs), including marijuana, for either medicinal or recreational reasons?
  • If yes, how often is your use?
  • Was the substance prescribed by a doctor?
  • Do you take any other prescriptions and/or over-the-counter medicine(s), vitamins, herbs and/or supplements?

  • Women Only:

  • Are you taking birth control pills?
  • Are you pregnant?
  • Are you nursing?

  • ALLERGIES: Please mark your answers to the following questions.

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  • Medical & Surgical History

  • Date of last physical exam:
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  • Format: (000) 000-0000.
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  • Medical History Specific

    Do you have, or have you been diagnosed with, any of the following conditions?
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  • Cancer

  • Have you been diagnosed with Cancer?
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  • Medical Symptoms/General

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  • NOTE: It’s important for both the doctor and patient to talk honestly about the patient’s health before dental treatment starts.

  • I have answered the above questions completely, accurately and to the best of my ability.

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