Patient Dental & Medical Health History Information
PATIENT INFORMATION
Last Name
First Name
Middle Name
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Gender
Email
example@example.com
Emergency Contact Name
First Name
Last Name
Relationship
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
If you are completing this form for another person, what is your relationship to that person?
Have you and/or the patient had any changes in general health within the past year?
Yes
No
If Yes, please explain:
Date of last physical exam
-
Month
-
Day
Year
Date
DENTAL HISTORY & SYMPTOMS
What is the reason for today’s visit?
Are you currently experiencing any dental pain or discomfort?
Yes
No
If yes, where?
What was the date of last appointment?
-
Month
-
Day
Year
Date
When was the last time you had dental x-rays taken?
-
Month
-
Day
Year
Date
Please mark any symptoms or conditions you currently experience:
Bad breath
Bleeding gums
Clicking or popping jaw
Difficulty chewing
Dry mouth
Earaches
Food collection between teeth
Grinding teeth
Loose teeth
Mouth sores
Sensitivity to hot
Sensitivity to cold
Sensitivity to sweets
Swollen gums
Jaw pain
Headaches
Broken fillings
Orthodontic treatment
Periodontal treatment
Other
MEDICATIONS & OTHER PRODUCTS / SUBSTANCES
Are you taking any medications?
Yes
No
If yes, list all medications, vitamins, supplements, or herbal remedies:
Are you taking blood thinners?
Yes
No
Do you use tobacco products?
Yes
No
If yes, what type?
Do you consume alcohol?
Yes
No
If yes, how often?
Daily
Weekly
Occasionally
Women Only
Are you pregnant?
Yes
No
Are you nursing?
Yes
No
ALLERGIES
Are you allergic to or have you had reactions to:
Aspirin
Penicillin
Sulfa drugs
Local anesthetics
Latex
Codeine
Metal
Other
MEDICAL & SURGICAL HISTORY
Have you had any serious illnesses, surgeries, or hospitalizations?
Yes
No
If yes, explain:
Have you ever had:
Artificial joint replacement
Heart surgery
Heart attack
Stroke
Cancer
Chemotherapy
Radiation treatment
Diabetes
Thyroid disease
Kidney disease
Liver disease
Respiratory disease
High blood pressure
Low blood pressure
Osteoporosis
Seizures
Fainting spells
Sleep apnea
Anxiety
Depression
HIV/AIDS
Hepatitis
Tuberculosis
Other
MEDICAL HISTORY SPECIFIC
Please indicate if you currently have or have ever had any of the following:
Arthritis
Asthma
Blood disorder
Chronic pain
COPD
Digestive disorder
Eating disorder
Epilepsy
Frequent headaches
GERD / Acid reflux
Heart murmur
Heart disease
Immune disorder
Pacemaker
Sinus problems
Sleep disorder
TMJ disorder
Ulcers
Other
COMPLETION BY DENTIST
Office Use Only
Date
-
Month
-
Day
Year
Date
Dentist Signature
Treatment Notes
Continue
Continue
Should be Empty: