• Mc Dean DENTAL CARE

  • Date of birth:*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • MEDICAL HISTORY

  • Are you presently under the care of a Physician?*
  • Have you been hospitalized in the past 2 years?*
  • Are you taking any drugs or medications?*
  • Have you ever had any allergies to any medication?*
  • Do you suffer from any non-drug related allergies?*
  • Are you allergic to Penicillin?*
  • Are you allergic to latex?*
  • Do you bruise easily or have prolonged bleeding?*
  • Do you smoke?*
  • Do you have shortness of breath?*
  • Have you ever had chest pains?*

  • Do you have or have you ever had and of the following? (please circle)

  • Medical Conditions

  • WOMEN

  • Are you pregnant?*
  • Are you using Birth Control?*

  • CHILDREN

    Have you recently had any of the following?
  • Chicken Pox?*
  • Date
     - -
  • Measles?*
  • Date
     - -
  • Mumps*
  • Date
     - -
  • Strep throat*
  • Date
     - -
  • Tonsillitis*
  • Date
     - -

  • DENTAL HISTORY

  • Are your teeth sensitive to:
  • Do your gums bleed when:
  • Do your gums feel swollen or tender?
  • Do you have bad breath/taste in your mouth?
  • Do your jaws crack, pop or grate when you open widely?
  • Do you experience recurring headaches or migraines?
  • Do you grind or clench your teeth?
  • Does food ever catch between your teeth?
  • Have you ever had any problems with previous dental treatment?
  • Date:
     - -
  • Should be Empty: