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Medical and Dental History

"*" indicates required fields

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Appointment Date

MM slash DD slash YYYY

Patient Information

Patient Name:

Last

First Name

First

MI

Preferred Name

Medical History Information

Physician Name and Phone Number

Pharmacy Name and Phone Number

What is your estimate of your general health?

Excellent

Good

Fair

Poor

Do you take antibiotic premedication for your dental visits?*

Yes

No

Indicate which of the following conditions you have or have had. By checking the box it will indicate a "YES" response, leaving blank will indicate a "NO" response.

*Pre-Med - Amox

*Pre-Med - Clind

*Pre-Med - Other

Afib

Allergy - Aspirin

Allergy - Codeine

Allergy - Erythro

Allergy - Hay Fever

Allergy - Latex

Allergy - Other

Allergy - Penicillin

Allergy - Sulfa

Anemia

Arthritis

Artificial Joints

Asthma

Blood Disease

Blood Pressure-High

Blood Pressure-Low

Blood Thinners

Bone Density Drugs

Cancer

Chemical Dependency

Currently Pregnant

Diabetes

Dizziness/Fainting

Epilepsy

Gerd/Acid Reflux

Glaucoma

Head/ Jaw Injuries

Heart Attack

Heart Disease

Heart Murmur

Hepatitis

HIV/Aids

Kidney Disease

Liver Condition

Mental Disorders

MVP

Nervous Disorders

Pacemaker

Radiation/ Chemo

Respiratory/COPD

Rheumatic Fever

Rheumatism

Sinus Problems

STD

Stroke

Thyroid Conditions

Tuberculosis

Tumors

Ulcers

xOther

Untitled

Recently been hospitalized (illness or injury)

Presently being treated for any other illnesses

Subject to frequent headaches

Tobacco: Chew, smoke or vape

FEMALE: Taking birth control

If any conditions or alerts selected above need further clarification, please describe below:

Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment.

List all medications (prescription and non-prescription) including regular doses of aspirin:

confirmation*

By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes. This will serve as my electronic signature.

Dental History

Previous Dentist Name and Phone Number:

Date of most recent dental exam and dental x-rays:

How would you rate the condition of your mouth?

Excellent

Good

Fair

Poor

I routinely see my dentist every:

3 mo.

4 mo.

6 mo.

12 mo.

Not routinely

What is your immediate concern?

Is there anything about the appearance of your smile that you would like to change?

Have you experienced any of the following?

Had complications from past dental treatment

Had trouble getting numb

Had any reactions to local anesthetic

Had/have braces or orthodontic treatment

You experience dry mouth

Teeth sensitive to hot, cold, biting, sweets

Food gets trapped between any teeth

Have you ever whitened or bleached your teeth

Have you experienced popping and/or clicking of your jaw joint

Have/Had head,neck or jaw injury

Have/Had sores/lumps in or near mouth

Bite lips or cheeks

Headaches/Migraines

You have difficulty chewing

You clench or grind your teeth

You wear or have worn a bite appliance/night guard

Gums bleed when brushing or flossing

Treated for gum disease or were told you have lost bone around your teeth

Noticed an unpleasant taste or odor in your mouth

Experienced gum recession

Had any teeth become loose on their own (without injury)

Experienced a burning sensation in your mouth

You snore or wake up frequently during the night/Sleep Apnea

Missing teeth replaced with partials or dentures

Is there anything else you would like to add or elaborate?

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Response Date

MM slash DD slash YYYY

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