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Medical/Dental History Form

02 of 03

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

*Your Name :

*Last Name

Middle Name

*First Name

What is the reason for your visit today?
Date of last dental visit :
Last dental cleaning :
Last full mouth X-rays :
Previous dentist :
Telephone Number:	( )- -

Patient’s address :
	City :	State :
	Zip :

How often do you have dental examination?
What was done at your last dental visit?
How often do you brush your teeth?
How often do you floss?
What other dental aids do you use? (Interplak, toothpick, etc)
Do you have any dental problems now	Yes No
Please describe :

Are any of your teeth sensitive to:
Hot or cold?	Yes No
Sweets?	Yes No
Biting or Chewing?	Yes No
Have you noticed any mouth odors or bad tastes?	Yes No
Do you frequently get cold sores, blisters or any other oral lesions?	Yes No
Do your gums bleed or hurt?	Yes No
Have your parents experienced gum disease or tooth loss?	Yes No
Have you noticed any loose teeth or change in your bite?	Yes No
Does food tend to become caught in between your teeth?	Yes No
If yes, where?
Do you:
Clench or grind your teeth while awake or asleep?	Yes No
Bite your lips or cheeks regularly?	Yes No
Hold foreign objects with your teeth?	Yes No
(pencils, pipe, pins, nails, fingernails)	Yes No
Mouth breathe while awake or asleep?	Yes No
Have tired jaws, especially in the morning?	Yes No
Snore or have any other sleeping disorders?	Yes No
Smoke/chew tobacco or use other tobacco products?	Yes No
Have you ever had:
Orthodontic treatment?	Yes No
Oral Surgery?	Yes No
Periodontal treatment?	Yes No
Your teeth ground or the bite adjusted?	Yes No
A bite plate or mouth guard?	Yes No
A serious injury to the mouth or head?	Yes No
If so, please describe, including cause:
Have you experienced:
Clicking or popping of the jaw?	Yes No
Pain?(joint, ear, side of face)	Yes No
Difficulty in opening or closing the mouth?	Yes No
Difficulty in chewing on either side of the mouth?	Yes No
Headaches, neckaches or shoulder aches?	Yes No
Sore muscles (neck, shoulders)?	Yes No
Are you satisfied with your teeth’s appearance?	Yes No
Would you like to keep all of your teeth all of your life?	Yes No
Do you feel nervous about having dental treatment?	Yes No
If so, what is your biggest concern?
Have you ever had an upsetting dental experience?	Yes No
If so, please describe

Is there anything else about having dental treatment that you would like us to know? Yes No

If yes, please describe:

Medical History

1. Have you been under the care of a medical doctor during the past two years? Yes No
If yes for what:
Physician’s Name :
Telephone Number:	( )- -
Address :
	City :	State :
	Zip :

2. Have you taken any medication or drugs during the past two years?	Yes No
3. Are you taking any medication or drugs currently, including regular doses of aspirin or over-the-counter herbal medicines?	Yes No
If yes, Please list name and dosage:
4. Have you ever taken any prescription drugs for weight loss, including Fen-Phen (fenfluramine - phentermine); Pondimen (fenfluramine); and Redux (dexfenfluramine)?	Yes No
If yes to the above, did you have a medical exam for heart issues?	Yes No
5. Are you aware of having an allergic (or adverse) reaction to any medication or substance?	Yes No
If yes, please list:
6.Have you been a patient in the hospital during the past five years?	Yes No

7. Indicate which of the following you have had, or have at present. Click “yes” or no” to each item

Heart (Surgery, Disease, Attack)	Yes No
Chest pain	Yes No
Congenital Heart Disease	Yes No
Heart Murmur	Yes No
High Blood pressure	Yes No
Mitral valve prolapse	Yes No
Artificial heart valve	Yes No
Heart pacemaker	Yes No
Rheumatic fever	Yes No
Arthritis/Rheumatism	Yes No
Cortisone Medicine	Yes No
Swollen ankles	Yes No
Stroke	Yes No
Diet(Special/Restricted)	Yes No
Artificial joints(hip, knee, etc)	Yes No
Kidney Trouble	Yes No
Ulcers	Yes No
Diabetes	Yes No
Thyroid problems	Yes No
Glaucoma	Yes No
Contact lenses	Yes No
Emphysema	Yes No
Chronic cough	Yes No
Tuberculosis	Yes No

Asthma	Yes No
Hay fever	Yes No
Latex sensitivity	Yes No
Allergies or Hives	Yes No
Sinus trouble	Yes No
Radiation therapy	Yes No
Chemotherapy	Yes No
Tumors	Yes No
Hepatitis A B C	Yes No
Venereal disease	Yes No
A.I.D.S	Yes No
H.I.V positive	Yes No
Cold sores/fever blisters	Yes No
Blood transfusion	Yes No
Hemophilia	Yes No
Sickle cell disease	Yes No
Bruise easily	Yes No
liver disease	Yes No
Yellow jaundice	Yes No
Neurological disorders	Yes No
Epilepsy or Seizures	Yes No
Fainting or Dizzy spells	Yes No
Nervous/Anxious	Yes No
Psychiatric/Psychological care	Yes No

8.Do you use more than two pillows to sleep?	Yes No
9.Have you lost or gained more than 10 pounds in the past year?	Yes No
10.Do you have or have you had any disease, condition, or problem not listed?	Yes No
If yes, please list:
11. Women : Are you pregnant or think you may be pregnant? Yes Months No
Nursing?	Yes No
12. Women : Do you use birth control medications?	Yes No

* I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have y permission to ask the respective health care provider or agency, who may release such information to you. I will notify the dentist of any changes in my health or medication.

Signature* :	Date :

Advanced Dental Group Located at 3909 Silver Lake Rd., St. Anthony, Minneapolis 55421.
Phone: 888-993-1449. www.advanceddentalgroup.com.