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?
YesNo
Physician’s Name:
Telephone home:
Date of last visit:
Do you smoke or use tobacco in any other form?
YesNo
Have you had any metal rods, pins or implants?
YesNo
Are you taking any prescription / Over-the-counter drugs?
YesNo
Explain:
Have you ever taken Fosamax, or any other bisphosphonate?
YesNo
Do you wear a cardiac pacemaker, or have you had heart surgery?
YesNo
When?
Are you required to take any medication before your dental visit?
YesNo
What?



For women:

Are you using a prescribed method of birth control?
YesNo
Are you pregnant?
YesNo
Week #:
Are you nursing?
YesNo

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

YesNo
Abnormal Bleeding / Hemophilia
YesNo
AIDS related complex
YesNo
Alcohol / Drug abuse
YesNo
Anemia
YesNo
Arthritis
YesNo
Artificial bones / Joints / Valves
YesNo
Asthma
YesNo
Blood transfusion
YesNo
Chemotherapy (Center, leukemia)
YesNo
Colitis
YesNo
Congenital heart defect
YesNo
Diabetes
YesNo
Difficulty breathing
YesNo
Emphysema
YesNo
Epilepsy / seizures
YesNo
Excessive bleeding
YesNo
Respiratory disease
YesNo
Artifical prosthesis
YesNo
Congenital heart disease
YesNo
X-Ray or cobalt treatment
YesNo
Fainting spells / seizures
YesNo
Frequent headaches
YesNo
Glaucoma
YesNo
Hay fever
YesNo
Heart attack / Surgery
YesNo
Heart murmur
YesNo
Hepatitis / jaundice
YesNo
Herpes / Fever blisters
YesNo
High blood pressure
YesNo
Allergies or Hives
YesNo
Hospitalized for any reason
YesNo
Kidney disease
YesNo
Liver disease
YesNo
Low blood pressure
YesNo
Lupus
YesNo
Angina pectoris
YesNo
Cerebral palsy
YesNo
Joint replacement
YesNo
Nervous disorder
YesNo
Tumors or growths
YesNo
Mitral valve prolapse
YesNo
Pacemaker
YesNo
Psychiatric treatment
YesNo
Radiation treatment
YesNo
Rheumatic / Scarlet fever
YesNo
Shingles
YesNo
Sickle cell disease / Traits
YesNo
Sinus problems
YesNo
Stroke
YesNo
Thyroid problems
YesNo
Tuberculosis (TB)
YesNo
Ulcers
YesNo
Venereal disease
YesNo
Tonsillitis
YesNo
Head injuries
YesNo
Heart failure
YesNo
Chicken pox
YesNo
Sinus Trouble
YesNo
Blood disease
YesNo
Drug addiction
Please list any serious medical condition(s) that you have ever had:

Are you allergic to any of the following?

YesNo
Aspirin
YesNo
Penicillin
YesNo
Jewelry / Metals
YesNo
Anesthetic (Novocain, ETC)
YesNo
Dental anesthetics
YesNo
Other
YesNo
Erythromycin
YesNo
Sulfa Drugs
YesNo
Codeine
YesNo
Tetracycline
YesNo
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?
YesNo
Do you require antibiotics before dental treatment?
YesNo
Your current dental health is:
GoodFairPoor
Have you ever had a serious/difficult problem associated with any previous dental work?
YesNo
Do you floss daily?
YesNo
Brush daily?
YesNo
Type of bristles on your toothbrush?
HardMediumSoft
Have you ever had gum treatment?
YesNo
Do your gums ever bleed?
YesNo
Ever Itch?
YesNo
Have you ever had periodontal disease?
YesNo
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?
YesNo
Are your teeth sensitive to
HeatCold?
Anything else?
Do you have any loose teeth?
YesNo
Do you still have wisdom teeth?
YesNo
Would you like fresher breath?
YesNo
Whiter teeth?
YesNo
Are you happy with the way your smile looks?
YesNo
If not, what would you change?
*Signature:
Date:
Verification:
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