Medical History Page 2
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2Sickle Cell Disease Yes No
Hepatits C or D
Yes No
Bruise Easily
Yes No
Sinus Trouble
Yes No
Pacemaker
Yes No
Jaundice
Yes No
Artificial Joints
Yes No
Night Sweats
Yes No
Kidney Trouble
Yes No
Thyroid Disease
Yes No
Stroke
Yes No
Diabetes
Yes No
Anemia
Yes No
Drug Addiction
Yes No
Chemotherapy
Yes No
Blood Transfusion Yes No
Cold Sores
Yes No
Cancer
Yes No
Mitral Valve
Prolapse (MVP)
Yes No
Radiation Therapy
Yes No
Transplant
Yes No
Dental History
1. Date of last dental exam:____________________ Date of last dental x-rays: ____________________________________________
2. Previous dentist's name / location:___________________________________________________________________________________
3. Are you having tooth or gum pain at this time?
Yes No
4. Do you feel nervous about having dental treatment?
Yes No
5. Have you ever had a bad experience in a dental office?
Yes No
6. Do your gums bleed when brushing / flossing?
Yes No
7. Have you ever seen a periodontist?
Yes No
8. Have you ever had a “deep cleaning” (Scaling and Root Planing)?
Yes No
9. Is there anything you would like to speak with the Doctor about in private?
Yes No
10. Would you be interested in discussing ways to improve your smile?
Yes No
If yes, please explain: ____________________________________________________________________________________________________
Do you have any of the following dental concerns:
Clicking in jaw joint
Yes No
Sensitivity to:
Hot
Cold
Sweets Biting
Pain in or around your ears
Yes No
Swelling
Bleeding Gums
Difficulty opening or closing
Yes No
Bad Taste
Bad Breath
Difficulty chewing
Yes No
Food Catching
Tooth Pain
History of trauma to jaw or face Yes No
Clenching
Grinding
Diagnosis of TMJ/TMD
Yes No
Other: __________________________________________________
I understand the importance of a truthful health history and realize that incomplete information may have
an adverse effect on my treatment. To the best of my knowledge, the information above is complete and
accurate.
Signature: _____________________________________________________________ Date_________________________________________
Doctor’s Signature____________________________________________________________________________________________________
Doctor’s Notes:
Alliance Dentistry NC Adult Medical History
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