MEDICAL + DENTAL HISTORY FORM TODAY'S DATE * MM DD YYYY PATIENT'S NAME * PREFERRED NAME * DENTAL HISTORY * WHY HAVE YOU COME TO THE DENTIST TODAY? ARE YOU CURRENTLY IN PAIN? * YES NO PREVIOUS / PRESENT DENTIST * DATE OF LAST DENTAL EXAM * MM DD YYYY DO YOU HAVE A PRE-EXISTING CONDITION THAT REQUIRES ANTIBIOTICS PRIOR TO DENTAL WORK? * YES NO NOT SURE HOW DO YOU FEEL ABOUT YOUR CURRENT DENTAL HEALTH? * GOOD FAIR POOR NOT SURE DO DENTAL VISITS CAUSE YOU ANXIETY? * 0 NONE 1 2 3 4 5 EXTREME DO YOU FLOSS * YES NO DO YOU BRUSH DAILY? * YES NO DO YOUR GUMS BLEED WHILE BRUSHING OR FLOSSING? * YES NO SOMETIMES PLEASE EXPLAIN HAVE YOU EVER HAD PERIODONTAL DISEASE? * YES NO ARE YOUR TEETH SENSITIVE TO ANY OF THE FOLLOWING? * HOT COLD SWEETS HAVE YOU HAD ORTHODONTIC TREATMENT? * YES NO IF SO, DO YOU STILL WEAR RETAINERS? YES NO ARE YOU INVOLVED IN ANY CONTACT SPORTS? * YES NO ARE ANY OF YOUR TEETH LOOSE? * YES NO DO YOU STILL HAVE YOUR WISDOM TEETH? * YES NO NOT SURE ARE YOU WATE OR HAVE YOU BEEN TOLD THAT YOU SNORE? * YES NO DO YOU CLENCH OR GRIND YOUR TEETH? * YES NO DO YOU EVER EXPERIENCE JAW PAIN OR WAKE UP WITH HEADACHES? * YES NO ARE YOU HAPPY WITH THE WAY YOUR SMILE LOOKS? * YES NO IF NO, WHAT WOULD YOU LIKE TO CHANGE? MEDICAL HISTORY PLEASE CHECK ANY CONDITION THAT YOU MAY HAVE EXPERIENCED. * *Allergy Not listed *No Epinephrine .Alzheimer's disease .Dementia Acid Reflux a-Fib Allergy - Latex Allergy- Codeine Allergy Metal Allergy- Penicillin Allergy- Sulfa Allergy-Aspirin Allergy-Tetracyclin Anemia Anxiety Arthritis Arthritis-Rheumatoid Artificial Joints Aspirin Therapy Asthma Birth Control Med Birth Control Meds Bleeding easily Blood Disease Blood Pressure-High Blood Pressure-low Blood Thinner Cancer Chemotherpy Chronic Cough Chronic Fatigue Chronic Pain Colitis/Chron's/IBS COPD COVID19 CPAP Depression Diabetes Dizziness Epilepsy Fainting Fibromyalgia Glaucoma Hay Fever Headache/migraine Hearing loss Heart attack Heart Defects Heart Disease Heart Murmur Heart pacemaker Heart palpations Heart stents placed Heart valuve replace Hepatitis Herpes/Fever Blister High Cholesterol HIV+/AIDS hormone replacement Hyper Active/ADD Insomnia Intestinal disorder Kidney Disease Liver Disease Lupus Medication OTC Medication Prescribe Mental Disorders Mitral ValveProlapse Nervous Disorders Osteoporosis Pregnant Radiation Treatment Rheumatic Fever Seizures Shortness of breath Sinus Problems Sleep Disorder/Apnea Smoke/Vape/Chew Snoring Stroke Substance Abuse Thyroid Disease TMJD- jaw pain Tuberculosis Tumors/Growths Ulcers PLEASE LIST ANY MEDICAL CONDITIONS NOT LISTED ABOVE: PLEASE LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING. PLEASE LIST ANYTHING ADDITIONAL THAT CAUSES ALLERGIC REACTIONS: PHYSICIAN'S NAME + PHONE NUMBER * WHEN WAS YOUR LAST MEDICAL CHECK UP? * MONTH / YEAR ARE YOU CURRENTLY UNDER THE CARE OF A PHYSICIAN? * IF YES, PLEASE EXPLAIN DO YOU SLEEP WELL? * YES NO HOW MANY HOURS OF UNINTERRUPTED SLEEP DO YOU GET A NIGHT? * DO YOU FEEL TIRED DURING THE DAY? * YES NO DO YOU SMOKE OR USE TOBACCO IN ANY FORM? * YES NO DO YOU CONSUME ALCOHOL? * YES NO IF YES, HOW OFTEN PER WEEK? HAVE YOU EVER TAKEN BONE REPLACEMENT THERAPY MEDS? * YES NO IF YES, WHAT YEAR + FOR HOW LONG? Have you ever taken Phen-Fen, Redux or Pondimin (weightloss medication)? * YES NO If yes, have you had a cardiac evaluation to check your hearts health? * YES NO IF YES, WHAT ARE THE RESULTS? AUTHORIZATION * I affirm the information I have given is correct to the best of my knowledge, and that it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary services I may need. I assign the Doctor all insurance benefits. I understand that I am responsible for payment of services rendered, any deductible, and co-payment that my insurance does not cover. By checking this box, I acknowledge that I have read this statement and agree to the contents. Thank you!
