• Today's Date
  • Full Name
  • Birthdate
  • Address
  • Unit#
  • City
  • State
  • Zip
  • Cell Phone
  • Home Phone
  • Work Phone
  • E-mail


Medical History
  • Do you require antibiotics before dental treatment?
  • Yes No
  • Have you been hospitalized or under the care of a medical doctor during the past 2 years?
  • Yes No
  • If yes, for what?
  • Physician's name IF new
  • Office Phone
  • List ANY and ALL Prescriptions, Over-The-Counter Medications, and Natural Supplements you are currently taking:
  • Do you use tobacco?
  • Yes No
  • If so what type:
  • Dip Smoke E-cig
  • Others:
  • Do you use alcohol or any other controlled substance?
  • Yes No
  • Other
  • Bone Replacement Therapy
  • Fosamax Boniva Actonel Evista Forted Zometa
  • Other
  • via:
  • Pill Injection IV
  • Yes No
    Heart (Surgery, Disease, Attack)
    Stroke
    Heart Murmur
    Heart Pacemaker
    Mitral Valve Prolapse (MVP)
    Artificial Heart Valve
    Rheumatic/Scarlet Fever
    High blood pressure
    Low blood pressure
    Atrial Fibrillation
  • Diabetes
  • Yes No
  • HbA1c score
  • Date
  • Joint Replacement Surgery
  • Yes No
  • When
  • Joint
  • GERD/acid reflux
  • Yes No
  • Cancer type
  • Yes No
  • Yes No
    Radiation/Chemotherapy
    Cold Sores/Herpes/Fever Blisters.
    Tuberculosis (TB)
    Hepatitis A,B, or C
    AIDS/HIV/ARC
    Venereal Disease/STD/HPV
  • Yes No
    Asthma
    Sinusitis/Hay Fever
    Allergies or Hives
    Emphysema/COPD
  • Yes No
    Alzheimer's or Dementia
    Epilepsy or Seizures
    Nervousness/Anxiety/Depression
    Thyroid Problems
  • Autoimmune Disease:
  • Lupus Celiac MS Crohn's Rheumatoid Arthritis Sjogren's
  • Other:
  • Yes No
    Do you occasionally snore?
    Have you stopped breathing or gasped for air while sleeping?
    Are you often sleepy during the day?
    Have you had a sleep study?
  • If so, when?
  • Have you been diagnosed with Sleep Apnea?
  • Yes No
  • Are you currently using or have used:
  • CPAP T.A.P Other device
  • Yes No
    Hearing disorder
    Alcohol/drug abuse
    Glaucoma
    Arthritis
    Anemia
    Blood disease
    Bruise Easily
  • Any other condition Not listed above:
ALLERGIES
  • Any allergy or adverse reaction to any of the following
  • Latex Anesthetics ("caine") Codeine
    Penicillin Sulfa Drugs Sedatives
    Erythromycin Aspirin Jewelry/Metals
    Tetracycline Iodine and Shellfish None (No known diagnosed allergies)
  • Other Antibiotics
  • Other


Dental History
  • Within the last YEAR, have you had:
  • Yes No
    Oral Surgery?
    Discomfort in your jaw joint (TMJ/TMD)?
    Serious injury to the mouth or head?
    Do your gums bleed when you floss or brush?
    Have you noticed any mouth odors or bad tastes?
  • If yes, reason for surgery?
  • Yes No
    Are you teeth sensitive to hot/cold?                          
    Do you clench or grind you teeth?
    Do you have frequent headaches?
    Do you have a Night Guard?
  • Are you using it?
  • Yes No
  • How often do you floss?
  • How often do you bruch your teeth?
  • If you use electric toothbrush:
  • Battery or Rechargeable Sonicare Oral-B
  • other
  • If you use a manual toothbrush: What type of bristles do you use?
  • Hard Medium Soft
  • Which toothpaste do you prefer?
  • Mouthwash?
  • Yes No
  • Brand:
  • Do you use other dental aids?
  • Yes No
  • Waterpik AirFloss Interdental Brushes Soft Picks Reach Flosser Toothpick other
  • Any homeopathic/natureal denal products?
  • Yes No
  • If so, which ones?
 Women Only:
  • Are you pregnant or think you may be pregnant?
  • Yes No
  • If Yes, what is your due date?
  • Are you taking birth control pills?
  • Yes No
  • Are you taking Hormone Replacement Therapy?
  • Yes No

 
  • Patient/Parent Signature
  • Date:
  • Dr. Signature:
  • _________________________
  • Updated on
  • ______________________
  • Patient Signature
  • ______________________
  • Staff Ints
  • ______________________
  • Updated on
  • ______________________
  • Patient Signature
  • ______________________
  • Staff Ints
  • ______________________
  • Updated on
  • ______________________
  • Patient Signature
  • ______________________
  • Staff Ints
  • ______________________
  • Updated on
  • ______________________
  • Patient Signature
  • ______________________
  • Staff Ints
  • ______________________
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