Update of Dental / Medical History
Please note that it is important to fill in all the fields before submitting. Thank you.
Print blank form to fill by hand
Name
*
First Name
Middle Name
Last Name
Gender
Please Select
Male
Female
Medical History
Do you have a personal physician?
Yes
No
Physician’s Name
Home Telephone Number
Please enter a valid phone number.
Date of last visit
-
Month
-
Day
Year
Date
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
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
Are you required to take any medication before your dental visit?
*
Yes
No
For women
Are you using a prescribed method of birth control?
*
Yes
No
Are you pregnant?
*
Yes
No
Week Number
*
Are you nursing?
*
Yes
No
Have you ever had any of the following diseases or medical problems
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
Artificial 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
*
Yes
No
Please list any serious medical condition(s) that you have ever had
Are you allergic to any of the following?
Aspirin
*
Yes
No
Penicillin
*
Yes
No
Jewelry / Metals
*
Yes
No
Anesthetic (Novocain, ETC)
*
Yes
No
Dental Anesthetics
*
Yes
No
Erythromycin
*
Yes
No
Sulfa Drugs
*
Yes
No
Codeine
*
Yes
No
Tetracycline
*
Yes
No
Latex
*
Yes
No
Other
*
Yes
No
If "Other" Please Describe
*
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
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
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