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Dental and Medical History

Print blank form to fill by hand

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

DENTAL HISTORY
Patient Name :
*Last Name :
Middle Name : *First Name :
Previous Dentist :
Telephone : ( )- -
Date of last dental visit :
Date of last x-rays:
Check all that apply
Bad breath
Bleeding gums
TMJ pain
Gum disease
Gag reflex
Broken fillings
Sensitive to sweets
Grind/clench teeth
Loose teeth
Sensitive to biting/chewing
Sensitive to hot/cold
Food packing between teeth
Bad dental experience in past
Do you smoke or use any tobacco products? Yes No
What and how often?
How often do you brush?
How often do you floss?
If you could change anything about your smile, what would it be?
Other information about your dental health
MEDICAL HISTORY
Physician :
Date of last exam :
Currently under doctor’s care? Yes No
Why?
Are you pregnant? Yes No Due Date :
Do you take birth control? Yes No Do you have panic attacks? Yes No
Are you allergic to: (check all that apply)
Penicillin Sulfa Drugs Codeine Aspirin Iodine Latex
Other :
List current medications:
Have you had prosthetic joint replacement surgery?
Do you snore? Yes No
Have you been diagnosed with sleep apnea? Yes No
Do you have or have you had any of the following: (Check all that apply)
AIDS/HIV+
Anaphylaxis
Arthritis
Epilepsy
Food allergy
Heart murmur
Psychiatric care
Cancer
Tonsillitis
Chemotherapy
Emphysema
Cough up blood
Diabetes
Kidney disease
Blood disease
Thyroid disease
Nervous problems
Heart problems
Tuberculosis
Radiation therapy
Persistent cough
High blood pressure
Jaw pain
Liver disease
Metal allergy
Back problems
Herpes
Respiratory disease
Drug use
Hepatitis/Jaundice
Low blood pressure
Shortness of breath
Rheumatic fever
Artificial heart valve
Mitral valve prolapse
Rapid weight loss/gain
Circulatory problems
Swelling of feet/ankles
Shingles
Anemia
Skin rash
Stroke
Headaches
Pacemaker
Ulcer
Hemophilia
Colitis
Other :
*Signature
Date
Appointment Request
Office Events
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Testimonial
Clint Bruyere, DDS
5 Clint Bruyere, DDS - reviews
"I have been more than pleased with your office and staff. You have gone above and beyond to get me in as a new patient and take care of the issues I had in a very efficient and timely manner. You all made me feel very comfortable and welcome and I appreciate all of you for your kindness and sincere concern. Thank You."
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