Patient Medical History
Phys Phone No.
Date of last exam:
Are you under medical treatment now?
Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
*If yes please explain:
Are you taking any medication including non-prescription medicine
If yes, what medications are you taking?
Have you ever taken Phen-Fen/Redux?
Do you use tobacco in any form?
Do you have any history of drug abuse?
Are you wearing contact lenses?
Do you have a chief dental complaint or concern today?
*If yes my concern is:
Are you allergic or have you had any reactions to the following:
Local Anethetics (e.g. Novocain)
Penicillin or Antibiotics
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?
High blood pressure
Fainting / Seizures
Low Blood Pressure
Aids or HIV infection
Sexually Trans. Disease
Recent Weight Loss
Mitral Valve Prolapse
Patient Medical History
Name of Previous Dentist:
Date of Last Exam:
Previous Dentist Location:
Date of Last Cleaning:
How nervous are you about coming to the dentist?
A little Nervous
Not Nervous At All
Have you ever had a bad dental experience?
Are your teeth sensitive to sweet or sour liquids/food?
Do your gums bleed while brushing or flossing?
Have you ever experienced any of the following problems in your jaw?:
*Pain (joint, ear, side of face)
*Difficulty in opening or closing
*Difficulty in chewing
Do you have frequent headaches?
Do you clench or grind your teeth?
Hav eyou had any head, neck, or jaw injuries?
Have you had any difficult extractions?
Have you had prolonged bleeding following extractions?
Have you had orthodontic treatment?
Do you wear dentures or partials?
If Yes, date of placement:
Are you happy with the way your smile looks?
Would you like to learn more about how you can improve your smile?
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.
Signature of patient (or parent if minor)