sumnersmilesdental - New Health History

New Health History
Patient Name
Date

MonthDayYear
Date
How often do you brush?
How often do you floss?
Manual or Electric tooth brush?
Physicians Name
Date of last visit

MonthDayYear
Date
Physicians phone#
Please enter a valid phone number.
Preferred pharmacy
Emergency contact
Please enter a valid phone number.
Please select all that apply

Bad Breath/Unpleasant TasteBurning Tongue/LipsSensitivity to HeatBleeding GumsLoose Teeth or Broken FillingsSensitivity to SweetsFinger Nail BitingPain Around EarFrequent HeadachesClenching/Grinding teethPeriodontal TreatmentShifting TeethLip or Cheek BitingSensitivity to ColdFood Impaction
Do you have or have you had: (please mark all that apply)

AnemiaChemotherapyRadiationPacemakerArthritis, RheumatismDiabetesJaw PainRespiratory DiseaseArtificial Heart ValvesGlaucomaLatex AllergySinus TroubleArtificial JointsHeart ProblemsKidney DiseaseThyroid ProblemsAsthmaHepatitis type__Liver DiseaseTuberculosisBack ProblemsHerpesLow blood PressureStrokeBleeding AbnormallyCancer / TumorHigh cholesterolUlcerHigh Blood PressureHIV Positive/AIDSOther

Have you ever had an Allergic reaction to

	Yes	No
Local Anesthetics (ie: novocaine)
Sulfa Drugs
Aspirin/Tylenol

Select "Yes" or "No":

	Yes	No
Do you use tobacco products?
Do you use alcohol? (social) (other)
Do you or have you used cocaine, Methamphetamine or other drugs?
Do you use Marijuana?
Do you have abnormal bleeding with injury?
For Women; are you taking Birth Control Pregnant or Nursing