Medical History Form

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Howard Family Dental
Medical History
Dental History
Patient Name (please print):____________________________________________________
(Please check any of the following that apply to you)
What would you like to do to improve your smile?
 Sensitivity (hot, cold, sweets, pressure)
 Whiten
 Discomfort when chewing
 Straighten
 Headaches, earaches, neck pain
 Close spaces
 Jaw joint pain
 Replace silver fillings with tooth colored fillings
 Teeth or fillings breaking
 Repair chipped teeth
 Bad breath/bad taste in mouth
 Replace missing teeth
 Bleeding, swollen or irritated gums
 Replace old crowns that don’t match other teeth
 Loose, chipped or shifting your mouth
 Grinding or clenching teeth
Do you have or have you ever had any of the following?
How long has it been since your last cleaning?
 Dentures  Partial Dentures
 Less than 1 yr  1-2 yrs  3-5 yrs  over 5 yrs
 Braces
 Periodontal (gum) treatments
What is most important about your visit today? ____________________________________________________________________________
_____________________________________________________
________________________________
_____________________________________
Name of previous dentist
Phone number
City & State
Why did you leave your previous dentist? ___________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Previous dental experiences: __________________________________________________________________________________________________
On a scale of 1 to 10 with 10 being the highest:
How important is your dental health to you?
1 2 3 4 5 6 7 8 9 10
Where would you rate your current dental health?
1 2 3 4 5 6 7 8 9 10
Sleep History
Have you ever had a sleep study or do you currently use a CPAP?
Yes No
Does your partner say that you snore?
Yes No
Do you take frequent naps during the day, or often feel tired?
Yes No
Other: ______________________________________________________________________________________________________
Medical History
Have you been under the care of a medical doctor during the past two years?
Yes No
If yes, for what? _____________________________________________________________________________________________________________
Physician’s name: __________________________________________________ Last visit to Physician: _________________________________
Do you have high blood pressure? Yes No
What is your normal blood pressure? ______________________________
Emergency Contact: ________________________________________________ Phone Number: ____________________________________
Are you allergic or have you had a reaction to the following:
Local Anesthetic
Updates:
Yes No
Penicillin or other antibiotics
Initials ____________ Date ________________
Yes No
Aspirin, Ibuprofen or Tylenol
Initials ____________ Date ________________
Yes No
Codeine, Valium or other sedatives
Initials ____________ Date ________________
Yes No
Latex or metals
Initials ____________ Date ________________
Yes No
Patient Signature: ________________________________________________________________ Date: ______________
Doctor Signature: _________________________________________________________________ Date: _______________

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