Update of Dental/Medical History

Please note that it is important to fill in all the fields before submitting. Thank you.

*Name

*Last name

Mid name

*First name


[honeypot country]

Medical History

Do you have a personal physician?
 Yes No
Physician’s Name:
Telephone home:
Date of last visit:
Do you smoke or use tobacco in any other form?
 Yes No
Have you had any metal rods, pins or implants?
 Yes No
Are you taking any prescription / Over-the-counter drugs?
 Yes No
Explain:
Have you ever taken Fosamax, or any other bisphosphonate?
 Yes No
Do you wear a cardiac pacemaker, or have you had heart surgery?
 Yes No
When?
Are you required to take any medication before your dental visit?
 Yes No
What?



For women:

Are you using a prescribed method of birth control?
 Yes No
Are you pregnant?
 Yes No
Week #:
Are you nursing?
 Yes No

Have you ever had any of the following diseases or medical problems?

 Yes No
Abnormal Bleeding / Hemophilia
 Yes No
AIDS related complex
 Yes No
Alcohol / Drug abuse
 Yes No
Anemia
 Yes No
Arthritis
 Yes No
Artificial bones / Joints / Valves
 Yes No
Asthma
 Yes No
Blood transfusion
 Yes No
Chemotherapy (Center, leukemia)
 Yes No
Colitis
 Yes No
Congenital heart defect
 Yes No
Diabetes
 Yes No
Difficulty breathing
 Yes No
Emphysema
 Yes No
Epilepsy / seizures
 Yes No
Excessive bleeding
 Yes No
Respiratory disease
 Yes No
Artifical prosthesis
 Yes No
Congenital heart disease
 Yes No
X-Ray or cobalt treatment
 Yes No
Fainting spells / seizures
 Yes No
Frequent headaches
 Yes No
Glaucoma
 Yes No
Hay fever
 Yes No
Heart attack / Surgery
 Yes No
Heart murmur
 Yes No
Hepatitis / jaundice
 Yes No
Herpes / Fever blisters
 Yes No
High blood pressure
 Yes No
Allergies or Hives
 Yes No
Hospitalized for any reason
 Yes No
Kidney disease
 Yes No
Liver disease
 Yes No
Low blood pressure
 Yes No
Lupus
 Yes No
Angina pectoris
 Yes No
Cerebral palsy
 Yes No
Joint replacement
 Yes No
Nervous disorder
 Yes No
Tumors or growths
 Yes No
Mitral valve prolapse
 Yes No
Pacemaker
 Yes No
Psychiatric treatment
 Yes No
Radiation treatment
 Yes No
Rheumatic / Scarlet fever
 Yes No
Shingles
 Yes No
Sickle cell disease / Traits
 Yes No
Sinus problems
 Yes No
Stroke
 Yes No
Thyroid problems
 Yes No
Tuberculosis (TB)
 Yes No
Ulcers
 Yes No
Venereal disease
 Yes No
Tonsillitis
 Yes No
Head injuries
 Yes No
Heart failure
 Yes No
Chicken pox
 Yes No
Sinus Trouble
 Yes No
Blood disease
 Yes No
Drug addiction
Please list any serious medical condition(s) that you have ever had:

Are you allergic to any of the following?

 Yes No
Aspirin
 Yes No
Penicillin
 Yes No
Jewelry / Metals
 Yes No
Anesthetic (Novocain, ETC)
 Yes No
Dental anesthetics
 Yes No
Other
 Yes No
Erythromycin
 Yes No
Sulfa Drugs
 Yes No
Codeine
 Yes No
Tetracycline
 Yes No
Latex
Please list any other drugs / Materials that you are allergic to:

Dental History

Why have you come to the dentist today?
Are you currently in pain?
 Yes No
Do you require antibiotics before dental treatment?
 Yes No
Your current dental health is:
 Good Fair Poor
Have you ever had a serious/difficult problem associated with any previous dental work?
 Yes No
Do you floss daily?
 Yes No
Brush daily?
 Yes No
Type of bristles on your toothbrush?
 Hard Medium Soft
Have you ever had gum treatment?
 Yes No
Do your gums ever bleed?
 Yes No
Ever Itch?
 Yes No
Have you ever had periodontal disease?
 Yes No
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?
 Yes No
Are your teeth sensitive to
 Heat Cold?
Anything else?
Do you have any loose teeth?
 Yes No
Do you still have wisdom teeth?
 Yes No
Would you like fresher breath?
 Yes No
Whiter teeth?
 Yes No
Are you happy with the way your smile looks?
 Yes No
If not, what would you change?
*Signature:
Date:
Verification:
captcha