Dental Information & Medical History Form
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1DENTAL INFORMATION
MEDICATION
LIST
Reason for today’s visit:
Exam
Emergency
Consultation
Are you in pain? No Yes
How Long? ________________________
Please indicate (√) any of the following problems:
Please list all medications
Discomfort, clicking or popping in jaw. Lost/Broken Filling(s) Stained teeth
you are currently taking:
Red, swollen or bleeding gums.
Teeth grinding
Locking Jaw
MED
DOSAGE REASON
Sensitive tooth, teeth or gums.
Ringing in ears
Bad breath
_____________________
Blisters/Sores in or around the mouth.
Broken/Chipped tooth
_____________________
Other: ___________________________________________________________
_____________________
Do you require per-medication? Yes No Don‘t know
_____________________
Previous Dentist: ______________________ Phone #: __________________
_____________________
Last Dental exam: ___/___/___ Last Dental X-rays: ___/___/___
_____________________
_____________________
Times a day you brush? _______
Times a week you floss? __________
_____________________
How would you rate your smile?
1 2 3 4 5 6 7 8 9 10
(WORST)
(BEST)
_____________________
_____________________
_____________________
_____________________
MEDICAL HISTORY
Have you ever taken: Bisphosphonates (
Yes No
ex. Aredia/Fosamax)
Do you have or have you had any of the following diseases, medical conditions or procedures?
Y N Heart Attack / Stroke
Y N Thyroid Problems
Y N Cancer / Tumors
Y N Cosmetic Surgery
Y N Heart Surg. / Pacemaker Y N Kidney Problems
Y N Shingles
Y N Radiation Treatment
Y N Heart Murmur
Y N Liver Problems
Y N Hepatitis (A, B, C)
Y N Chemotherapy
Y N Rheumatic Fever
Y N Respiratory Problems
Y N HIV+ / AIDS / ARC
Y N Asthma
Y N Mitral Valve Prolapse
Y N Sinus Problems
Y N Arthritis/Rheumatism
Y N Difficulty Breathing
Y N Artificial Valves
Y N Stomach Problems/Ulcers
Y N Artificial Bones/Joints
Y N Diabetes / Hypoglycemic
Y N Heart Disease
Y N Venereal Disease
Y N Emphysema
Y N Glaucoma
Y N Congenital Heart Defect Y N Chemical Dependency
Y N Fainting/Seizure/Epilepsy Y N Anemia
Y N Blood Disease
Y N Tuberculosis TB
Y N Frequent Neck Pain
Y N Scarlet Fever
Y N Blood Thinners
Y N Bleeding Problems/Hemophilia Y N Nervousness
Y N Jaw Pain TMJ / TMD
Y N Back Problems
Y N Severe / Frequent Headaches
Y N Gastric Bypass
Y N Dialysis
List any other surgeries or medical conditions you have or ever had: __________________________
_________________________________________________________________________________
Are you allergic to any of the following? Latex Penicillin/Amox Tetracycline Aspirin
Dental Anesthetics/Epinephrine Foods: _____________ Others: ____________________
Do you use tobacco? No Yes/how used? __________ How much? _______ How long? _______
Please rate your overall general health from 1-10: _____ Do you wear contact lenses? Yes No
•
We invite you to discuss with us any questions regarding our services. The best Dental health services are based on a friendly,
mutual understanding between provider and patient.
•
Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with
the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made,
you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your
account. We require 24 business hours notice for all rescheduled or cancelled appointments
•
I have read & understand the privacy policy. I authorize the staff to perform any necessary services needed during diagnosis &
treatment. I also authorize the provider to release any information required to process insurance claims.
•
I understand the above information and guarantee this form was completed correctly to the best of my knowledge and
understand it is my responsibility to inform this office of any changes to the information I have provided.
Signature ________________________________ Date _______________
Adult Patient Parent or Guardian Spouse
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Parent category: Medical