Patient Name _________________________________
Birth date ____________ Phone #_________________
Are you under the care of a Physician? [] yes [] no
Why? _______________________________________
________________________________________
What medications or pills are you currently taking?
________________________________________
________________________________________
What Herbs or diet supplements do you take regularly?
________________________________________
Are you allergic to any medications or substances?
[] Aspirin [] Codeine [] Penicillin [] Latex [] Sulfa
[] Jewelry/Metals [] Other _____________________
_________________________________________
Have you ever been instructed to pre-medicate with
antibiotics before receiving dental care? [] yes [] no
Cancer/ Tumors
Radiation Tx
Chemotherapy
Asthma
Epilepsy / seizures
Kidney Disease
AIDS/ HIV
Hemophilia
Hepatitis
Liver Disease
Venereal Disease
Alcohol addiction
Drug addiction
Adult Health History
Dental History
Reason for today’s visit? _________________________________________________________________________
When was your last dental check-up? _________________ Last panoramic or full set of x-rays taken? ___________
How often do you brush your teeth? __________________ How often do you floss your teeth? _________________
Please check any dental problems that apply
Other concerns ______________________________________________________________________________
If you could improve your smile, what might you change?
Other concerns _______________________________________________________________________________
I understand that the information I have given is correct. I authorize release of this information for medical consultation and referral, as well as
insurance submission. I also understand that it is my responsibility to inform this office of any changes of my medical status.
_______________________________________________________________________
(Signed) (Date)
Have you experienced the following?
Rheumatic fever
Heart murmur
Mitral valve prolapse
Any heart problem
Heart Surgery
Pacemaker
Joint Replacement
High Blood Pressure
Diabetes
Fainting/ Dizziness
Sinus Problems
Smoke tobacco?
Chew tobacco?
Please list any medical condition not listed above.
___________________________________________
___________________________________________
___________________________________________
Yes No
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For Women: Are you pregnant? [] yes [] no
[] Hot, cold, sweet sensitivity
[] Swelling or lumps
[] Denture problems
[] Bleeding gums
[] Sores in the mouth
[] Bad Breath
[] Broken or chipped teeth
[] Loose teeth
[] Snoring
[] Excessive bleeding after extraction or surgery?
[] Toothache
[] Difficulty chewing
[] Jaw joint pain (TMJ)
[] Difficult to numb
[] Close spaces
[] Replace missing teeth
[] Straighten uneven teeth
[] Replace old fillings or crowns
[] Whiten teeth
[] Repair chipped teeth