Health History NameBirth date Date Format: MM slash DD slash YYYY Today’s Date Date Format: MM slash DD slash YYYY Dental History1.Reason for today’s Visit2.When was your last dental visit?3.How often do you brush your teeth?5. Do your gums bleed while brushing ?YesNo6. Do your gums bleed while flossing ?YesNo7. Do you feel pain in any of your teeth when you are brushing or flossing?YesNo8. Are your teeth sensitive to hot, cold,sweet or sour foods/liquids ?YesNo9. Have you noticed any loosening of your teeth ?YesNo10. Does food tend to become caught between your teeth ?YesNo11. Do you have any sores or lumps in or near your mouth ?YesNo12. Have you ever experienced any of the following ?YesNo a. Clicking? b. Pain (joint, ear, side of face) ? Difficulty in opening or closing ? Difficulty in chewing ? 13. Do you snore ?YesNo14. Have you had any head, neck, or jaw injuries ?YesNo15. Do you have frequent headaches ?YesNo16. Do you clench or grind your teeth while awake or asleep ?YesNo17. Do you bite your lips or cheeks frequently ?YesNo18. Have you ever hadYesNo 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 ?YesNo20. Have you ever had an upsetting experience in the dental office ?YesNo21. Is there anything about having treatment done that bothers you ?YesNoMedical HistoryAlthough 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 ?YesNo2. Have there been any changes in your general health in the past year ?YesNo3. Date of your last physical exam: Date Format: MM slash DD slash YYYY 4. Physician’s name:Address:Phone number:5. Are you now under a physicians care?YesNo6. Have you ever been hospitalized for any surgical operation or serious illness ?YesNo7. Are you taking any medicine(s) including nonprescription medicineYesNo8. Have you ever taken Fen-Phen/Redux ?YesNo9. Have you had any abnormal bleeding ?YesNo10. Do you bruise easily ?YesNo11. Have you ever required a blood transfusion ?YesNo12. Have you had a recent weight loss ?YesNo13. Do you use drugs or other substances for recreational purposes ?YesNo14. Do you use tobacco-Smoking? Snuff? Chew ?YesNo15. Do you drink alcoholic beverages ?YesNo16. Do you have a persistent cough or throat clearing ?YesNo17. Do you wear contact lenses?YesNo18. Do you have any disease, condition, or problem not listed above that you think we should know about ?YesNoWomen Only1. Are you pregnant or think you may be pregnant ?YesNo2. Are you nursing ?YesNo3. Are you on any form of birth control ?YesNoPLEASE LIST ALL MEDICINE(S):Medical History ContinuedAre you allergic to or have you had reactions to1. Local anesthetics like Novocain ?YesNo2. Penicillin? Other antibiotics ?YesNo3. Sulfa Drugs ?YesNo4. Barbiturates, sedatives, sleeping pills ?YesNo5. Aspirin ?YesNo6. Metals ?YesNo7. Latex ?YesNo8. Codeine ?YesNo9. Other ?YesNoOtherDo you have or have you ever had the following1. Rheumatic heart disease or Rheumatic fever ?YesNo2. Scarlet fever ?YesNo3. Heart defect ? Heart murmur ?YesNo4. Heart trouble? Angina? Heart attack?YesNo 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 ?YesNo6. Heart surgery ?YesNo7. High blood pressure ?YesNo8. Low blood pressure ?YesNo9. Hepatitis ? Jaundice ? Liver disease ?YesNo10. Stroke ?YesNo11. Sinus trouble ?YesNo12. Lung or breathing problems ?YesNo13. Asthma ? Hay fever ?YesNo14. Hives or skin rash ?YesNo15. Fainting spells? Seizures?YesNo16. Diabetes?YesNo17. Cancer ?YesNo18. Thyroid problems ?YesNo19. Allergies ?YesNo20. Arthritis ? Rheumatism ?YesNo21. Joint replacement? Implant ?YesNo22. Stomach ulcer ?YesNo23. Kidney trouble ?YesNo24. Tuberculosis ?YesNo25. Persistent cough ?YesNo26. Cough that produces blood ?YesNo27. AIDS or HIV infection ?YesNo28. Sexually transmitted disease ?YesNo28. Sexually transmitted disease ?YesNo29. Epilepsy ?YesNo30. Anemia ?YesNo31. Leukemia ?YesNo32. Glaucoma ?YesNo33. Acid reflux ? Persistent heartburn ?YesNoDo you have any disease, condition, or problem not listed above that you think we should know about?YesNoPlease ExplainHas a physician or previous dentist recommended that you take antibiotics prior to your dental treatment ?YesNoPlease ExplainTo 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 GuardianDate Date Format: MM slash DD slash YYYY