Patient Medical History
YesNo
YesNo
  1. Are you under medical treatment now?
  2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
    *If yes please explain:
  3. Are you taking any medication including non-prescription medicine
    If yes, what medications are you taking?
  4. Have you ever taken Phen-Fen/Redux?
  5. Do you use tobacco in any form?
  6. Do you have any history of drug abuse?
  7. Are you wearing contact lenses?
  8. Do you have a chief dental complaint or concern today?
    *If yes my concern is:
  1. Are you allergic or have you had any reactions to the following:
    2. Local Anethetics (e.g. Novocain)
    Penicillin or Antibiotics
    Sulfa Drugs
    Barbiturates
    Iodine
    Sedatives
    Aspirin
    Any Metals
    Latex Rubber
    Other:
    *Woman Only:
    A. Are you pregnant or think you may be pregnant?
    B. Are you nursing?
    C. Are you taking oral contraceptives?
Do You have any of the following?
YesNo
YesNo
YesNo
High blood pressure
Heart Attack
Rheumatic Fever
Swollen Ankles
Fainting / Seizures
Asthma
Low Blood Pressure
Epilepsy/Convulsions
Leukemia
Diabetes
Kidney Diseases
Aids or HIV infection
Thyroid Problem
Heart Disease
Cardiac Pacemaker
Heart Murmor
Angina
Frequently Tired
Anemia
Emphysema
Cancer
Arthritis
Joint Replacement
Hepatitis
Sexually Trans. Disease
Stomach Troubles/Ulcers
Chest Pain
Easily Winded
Stroke
Hay Fever
Tuberculosis
Radiation Therapy
Glaucoma
Recent Weight Loss
Liver Disease
Thyroid Disease
Respiratory Problems
Mitral Valve Prolapse
Other:
Patient Medical History
YesNo
YesNo
  1. How nervous are you about coming to the dentist?
    Very Nervous A little Nervous Not Nervous At All
  2. Have you ever had a bad dental experience?
  3. Are your teeth sensitive to sweet or sour liquids/food?
  4. Do your gums bleed while brushing or flossing?
  5. Have you ever experienced any of the following problems in your jaw?:
    6. *Clicking
    *Pain (joint, ear, side of face)
    *Difficulty in opening or closing
    *Difficulty in chewing
  6. Do you have frequent headaches?
  1. Do you clench or grind your teeth?
  2. Hav eyou had any head, neck, or jaw injuries?
  3. Have you had any difficult extractions?
  4. Have you had prolonged bleeding following extractions?
  5. Have you had orthodontic treatment?
  6. Do you wear dentures or partials?
    7. If Yes, date of placement:
  7. Are you happy with the way your smile looks?
  8. Would you like to learn more about how you can improve your smile?
  9. Would you be interested in whitening (bleaching) your teeth?
**Authorization and releaes
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release my information including diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.