Health History

Name

Birth date

Today’s Date

Dental History

1.Reason for today’s Visit

2.When was your last dental visit?

3.How often do you brush your teeth?

5. Do your gums bleed while brushing ?

Yes
No

6. Do your gums bleed while flossing ?

Yes
No

7. Do you feel pain in any of your teeth when you are brushing or flossing?

Yes
No

8. Are your teeth sensitive to hot, cold,sweet or sour foods/liquids ?

Yes
No

9. Have you noticed any loosening of your teeth ?

Yes
No

10. Does food tend to become caught between your teeth ?

Yes
No

11. Do you have any sores or lumps in or near your mouth ?

Yes
No

12. Have you ever experienced any of the following ?

Yes
No

a. Clicking?
b. Pain (joint, ear, side of face) ?
Difficulty in opening or closing ?
Difficulty in chewing ?

13. Do you snore ?

Yes
No

14. Have you had any head, neck, or jaw injuries ?

Yes
No

15. Do you have frequent headaches ?

Yes
No

16. Do you clench or grind your teeth while awake or asleep ?

Yes
No

17. Do you bite your lips or cheeks frequently ?

Yes
No

18. Have you ever had

Yes
No

a. Orthodontic treatment (braces) ?
b. Oral surgery ?
c. Gum treatment ?
d. Your teeth ground or the bite adjusted ?

19. Are you satisfied with the appearance of your teeth ?

Yes
No

20. Have you ever had an upsetting experience in the dental office ?

Yes
No

21. Is there anything about having treatment done that bothers you ?

Yes
No

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important inter-relationship with the dentistry that you will be receiving. Thank you for answering the following questions.

1. Are you in good health ?

Yes
No

2. Have there been any changes in your general health in the past year ?

Yes
No

3. Date of your last physical exam:

4. Physician’s name:

Address:

Phone number:

5. Are you now under a physicians care?

Yes
No

6. Have you ever been hospitalized for any surgical operation or serious illness ?

Yes
No

7. Are you taking any medicine(s) including nonprescription medicine

Yes
No

8. Have you ever taken Fen-Phen/Redux ?

Yes
No

9. Have you had any abnormal bleeding ?

Yes
No

10. Do you bruise easily ?

Yes
No

11. Have you ever required a blood transfusion ?

Yes
No

12. Have you had a recent weight loss ?

Yes
No

13. Do you use drugs or other substances for recreational purposes ?

Yes
No

14. Do you use tobacco-Smoking? Snuff? Chew ?

Yes
No

15. Do you drink alcoholic beverages ?

Yes
No

16. Do you have a persistent cough or throat clearing ?

Yes
No

17. Do you wear contact lenses?

Yes
No

18. Do you have any disease, condition, or problem not listed above that you think we should know about ?

Yes
No

Women Only

1. Are you pregnant or think you may be pregnant ?

Yes
No

2. Are you nursing ?

Yes
No

3. Are you on any form of birth control ?

Yes
No

PLEASE LIST ALL MEDICINE(S):

Medical History Continued

Are you allergic to or have you had reactions to

1. Local anesthetics like Novocain ?

Yes
No

2. Penicillin? Other antibiotics ?

Yes
No

3. Sulfa Drugs ?

Yes
No

4. Barbiturates, sedatives, sleeping pills ?

Yes
No

5. Aspirin ?

Yes
No

6. Metals ?

Yes
No

7. Latex ?

Yes
No

8. Codeine ?

Yes
No

9. Other ?

Yes
No

Other

Do you have or have you ever had the following

1. Rheumatic heart disease or Rheumatic fever ?

Yes
No

2. Scarlet fever ?

Yes
No

3. Heart defect ? Heart murmur ?

Yes
No

4. Heart trouble? Angina? Heart attack?

Yes
No

a. Do you have pain in your chest upon exertion?
b. Are you ever short of breath after mild exercise?
c. Do your ankles swell?
d. Do you get short of breath when you lie down?

5. Pacemaker ?

Yes
No

6. Heart surgery ?

Yes
No

7. High blood pressure ?

Yes
No

8. Low blood pressure ?

Yes
No

9. Hepatitis ? Jaundice ? Liver disease ?

Yes
No

10. Stroke ?

Yes
No

11. Sinus trouble ?

Yes
No

12. Lung or breathing problems ?

Yes
No

13. Asthma ? Hay fever ?

Yes
No

14. Hives or skin rash ?

Yes
No

15. Fainting spells? Seizures?

Yes
No

16. Diabetes?

Yes
No

17. Cancer ?

Yes
No

18. Thyroid problems ?

Yes
No

19. Allergies ?

Yes
No

20. Arthritis ? Rheumatism ?

Yes
No

21. Joint replacement? Implant ?

Yes
No

22. Stomach ulcer ?

Yes
No

23. Kidney trouble ?

Yes
No

24. Tuberculosis ?

Yes
No

25. Persistent cough ?

Yes
No

26. Cough that produces blood ?

Yes
No

27. AIDS or HIV infection ?

Yes
No

28. Sexually transmitted disease ?

Yes
No

28. Sexually transmitted disease ?

Yes
No

29. Epilepsy ?

Yes
No

30. Anemia ?

Yes
No

31. Leukemia ?

Yes
No

32. Glaucoma ?

Yes
No

33. Acid reflux ? Persistent heartburn ?

Yes
No

Do you have any disease, condition, or problem not listed above that you think we should know about?

Yes
No

Please Explain

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment ?

Yes
No

Please Explain

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.

Signature of Patient, Parent, or Guardian

Date