• Med-Dental History

  • Format: (000) 000-0000.
  • Have you had any medical care within the past two years?*
  • Have you taken any medication or drugs during the past two years?*
  • Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosages of aspirin?*
  • Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or other bisphosphonates?*
  • Are you aware of having an allergic (or adverse) reaction to any substance or medication?*
  • Have you been a patient in the hospital during the past five years?*

  • Indicate which of the following you have had, or have at present. Select “yes” or “no” to each item.

  • Heart (Surgery, Disease, Attack)*
  • Chest Pain*
  • Congenital Heart Disease*
  • Heart Murmur*
  • High / Low Blood Pressure*
  • Artificial Heart Valve / Pacemaker*
  • Mitral Valve Prolapse*
  • Rheumatic Fever*
  • Arthritis / Rheumatism*
  • Cortisone Medicine*
  • Swollen Ankles*
  • Stroke*
  • Diet (Special / Restricted)*
  • Artificial Joints (hip, knee, etc.)*
  • Kidney Trouble*
  • Ulcers*
  • Diabetes*
  • Thyroid Problems*
  • Glaucoma*
  • Contact lenses*
  • Emphysema*
  • Tuberculosis*
  • Chronic Cough*
  • Asthma*
  • Hay Fever / Allergy / Hives*
  • Latex Sensitivity*
  • Sinus Trouble*
  • Radiation Therapy*
  • Chemotherapy*
  • Tumors*
  • Hepatitis*
  • Select Type*
  • Venereal Disease*
  • A.I.D.S / H.I.V. Positive*
  • Cold Sores / Fever Blisters*
  • Blood Transfusion*
  • Hemophilia*
  • Sickle Cell Disease*
  • Bruise Easily*
  • Liver Disease / Yellow Jaundice*
  • Neurological Disorders*
  • Epilepsy or Seizures*
  • Fainting or Dizzy Spells*
  • Nervous / Anxious*
  • Psychiatric / Psychological Care*
  • Cancer*
  • COVID-19 or related*
  • Have you lost or gained more than 10 pounds in the past year?*
  • Do you have or have you had any disease, condition, or problem not listed?*
  • Are you pregnant or think you could be pregnant?*
  • Nursing?*
  • Do you use birth control prescriptions?*

  • I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.

  • Date*
     - -

  • Dental History

  • Welcome! So that we may provide you with the best possible care please complete both sides of this medical/dental history form. All information is completely confidential.

  • Date of Last Dental Visit
     - -
  • Last Dental Cleaning
     - -
  • Last Full Mouth X-rays
     - -
  • Format: (000) 000-0000.
  • Have you ever used or are currently using topical fluoride?*
  • What other dental aids do you use? (Interplak, toothpick, etc.)*
  • Do you have any dental problems now?*

  • Are any of your teeth sensitive to:

  • Hot or cold?*
  • Sweets?*
  • Biting or Chewing?*
  • Have you noticed any mouth odors or bad tastes?*
  • Do you frequently get cold sores, blisters or any other oral lesions?*
  • Do your gums bleed or hurt?*
  • Have your parents experienced gum disease or tooth loss?*
  • Have you noticed any loose teeth or change in your bite?*
  • Does food tend to become caught in between your teeth?*

  • Do you:

  • Clench or grind your teeth while awake or asleep?*
  • Bite your lips or cheeks regularly?*
  • Hold foreign objects with your teeth? (pencils, pipe, etc.)*
  • Mouth breathe while awake or asleep?*
  • Have tired jaws, especially in the morning?*
  • Snore or have any other sleeping disorders?*
  • Smoke / chew tobacco or use other tobacco products?*

  • Have you ever had:

  • Orthodontic Treatment?*
  • Oral Surgery?*
  • Periodontal Treatment?*
  • Your teeth ground or the bite adjusted?*
  • A bite plate or mouth guard?*
  • A serious injury to the mouth or head?*

  • Have you experienced:

  • Clicking or popping of the jaw?*
  • Pain? (joint, ear, side of face)*
  • Difficulty in opening or closing the mouth?*
  • Difficulty in chewing on either side of the mouth?*
  • Headaches, neckaches or shoulder aches?*
  • Sore muscles (neck, shoulders)?*
  • Are you satisfied with your teeth’s appearance?*
  • Would you like to replace your silver fillings?*
  • Would you like to keep all of your teeth all of your life?*
  • Do you feel nervous about having dental treatment?*
  • Have you ever had an upsetting dental experience?*
  • Have you ever been told to take a pre-medication prior to dental treatment?*
  • Is there anything else about having dental treatment that you would like us to know?*
  • Date*
     - -
  • Should be Empty: