Patient Information Form - Stony Creek Dentistry Page 2
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3Patient Medical History:
Name of Physician: _________________________________ Last Exam: ________________ Office Phone: _____________
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No
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No
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1. Are you under Medical Treatment now?
4. Do you smoke or use tobacco products?
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2. Are you taking any Medications?
5. Do you use controlled substances?
If yes, what medication(s) are you taking? _______
6. Have you been Hospitalized for any surgical operation
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_____________________________________
or serious illness within the last 5 years?
_____________________________________
If yes, please explain _________________________
3. Do you have or have you had any of the following?
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Allergies:
Diabetes
Leukemia
Respiratory Problems
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Latex
Penicillin
Epilepsy/Seizures
Liver Disease
Rheumatic Fever
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Excessive Bleeding
Sulfa
Codeine
Low Blood Pressure
Sinus Problems
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Iodine
Metals
Fainting/Dizziness
Lung Disease
Skin Rash/Hives
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Other ___________
Glaucoma
Nervous Disorders
Spina Bifida
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Heart Disease
Nursing
Aids/HIV
Stomach Problems
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Heart Murmur
Anemia/Hemophilia
Stroke
Mitral Valve Prolapse
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Arthritis
Heart Attack
Pacemaker
TMJ and/or Jaw Pain
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Artificial Joints/Parts
Hepatitis
Pregnancy
Thyroid Problem
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Asthma
High Blood Pressure
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Tuberculosis
Due Date
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Pre-Medication
Blood Disease
Joint Replacements
Ulcers
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Cancer/Tumor
Kidney Disease
Radiation Treatment
Other________________
Patient Dental History:
Name of Previous Dentist ________________________________________ Date of Last Exam or Cleaning ________________
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1. Have you ever had any complications during/following dental treatment?
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No
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2. Are your teeth sensitive to hot, cold or sweet liquids/foods?
Yes
No
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3. Do you have pain in your teeth or a certain tooth?
Yes
No
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4. Have you ever had clicking or pain in your jaws or difficulty opening or closing?
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No
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5. Do you have frequent headaches?
Yes
No
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6. Do you clench or grind your teeth?
Yes
No
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7. Have you ever had a difficult extraction(s) or prolonged bleeding following an extraction in the past?
Yes
No
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8. Have you had any orthodontic treatment (braces)?
Yes
No
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9. Do you like your smile?
Yes
No
____________________
10. If you could change one thing about your smile or teeth, what would it be?
Authorization and Release:
I certify that I have read, answered and understand the above information to the best of my knowledge. I understand that providing
incorrect information can be dangerous to my health. If I ever have any change in my health, I will inform the doctors at the next
appointment without fail. I also authorize the dentist(s) and/or dental office to release any information to third party payors and/or other
healthcare practitioners.
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