• 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
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  • Last Dental Cleaning
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  • Last Full Mouth X-rays
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  • Format: (000) 000-0000.
  • Have you ever used or are currently using topical fluoride?
  • Do you have any dental problems now?
  • Rows
  • Does food tend to become caught in between your teeth?
  • Rows
  • Rows
  • A serious injury to the mouth or head?
  • Rows
  • Are you satisfied with your teeth's appearance?
  • 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?

  • MEDICAL HISTORY

  • Format: (000) 000-0000.
  • Have you ever had medical care in the past two years?
  • 2. Have you taken any medication or drugs during the past two years?
  • 3. Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosages of aspirin?
  • 4. Have you ever taken prescription medications for weight loss (diet pills)?
  • If yes, did you take any of the following? (check if yes)
  • If yes to any of the above, did you have a medical exam for heart issues?
  • 5. Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or other similar drugs?
  • 6. Are you aware of having an allergic (or adverse) reaction to any substance or medication?
  • 7. Have you been a patient in the hospital during the past five years?
  • Rows
  • 9. Have you lost or gained more than 10 pounds in the past year?
  • 10. Do you have or have you had any disease, condition, or problem not listed?
  • 11. Women: Are you pregnant or think you could be pregnant?
  • Nursing
  • 12. 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:
     - -
  • Should be Empty: