MEDICAL HISTORY

First Name *

Last Name *

Date of Birth *

In case of emergency, contact *

Phone *

1. Are you being treated for any medical condition at the present or have been treated within the past year? If so, why?

Yes

Not sure / May be

2. When was your last medical checkup?

Date

3. Has there been any change in your general health in the past year? If yes, please explain.

Yes

Not sure / May be

4. Are you taking any medications, non-prescription drugs or herbal supplements of any kind? If yes, please list (incl. names & dosages).

Yes

Not sure / May be

5. Do you have any allergies? If yes, please list using the categories: a) medication b) latex/rubber products c) other e.g. hayfever, foods

Yes

Not sure / May be

6. Have you ever had a peculiar or adverse reaction to any medicines or injection? If yes, please explain.

Yes

Not sure / May be

7. Do you have or have you ever had asthma?

Yes

May be / Not sure

8. Do you have or have you ever had any heart or blood pressure problems?

Yes

Not sure / May be

9. Do you have or have you ever had a heart murmur, mitral valve prolapse or rheumatic fever?

Yes

Not sure / May be

10. Do you have a prosthetic or artificial joint?

Yes

Not sure / May be

11. Have you ever been advised by your doctor/dentist to take antibiotics before dental treatment?

Yes

Not sure / May be

12. Do you have any conditions or therapies that could affect your immune system e.g. leukemia, AIDS, HIV infection, radiotherapy, and chemotherapy?

Yes

Not sure / May be

13. Have you ever had hepatitis, jaundice or liver disease?

Yes

Not sure / May be

14. Do you have a bleeding problem or bleeding disorder?

Yes

Not sure / May be

15. Have you ever been hospitalized for any illness or operations? If yes, please explain.

Yes

Not sure / May be

17. Are there any conditions or diseases not listed above that you have or have had? If yes, please list.

Yes

Not sure / May be

18. Are there any diseases or medical problems that run in your family? (e.g. diabetes, cancer or heart disease)

Yes

Not sure / May be

19. Do you smoke or chew tobacco products?

Yes

May be / Not sure

20. Are you nervous during dental treatment?

Yes

Not sure / May be

21. For women only: Are you breast-feeding or pregnant? If pregnant, what is the expected delivery date?

Yes

Not sure / May be

Blood Pressure Reading (office use)

DENTAL HISTORY

1. When was your last dental visit?

2. When did you last have dental x-rays?

3. How often do you brush your teeth?

4. How often do your floss your teeth?

5. Have you been seeing a dentist regularly?

Yes

Not sure / May be

6. Do any of your teeth ache?

Yes

Not sure / May be

7. Do your gums bleed when you brush?

Yes

May be / Not sure

8. Do you have any pain when you chew?

Yes

May be / Not sure

9. Do you feel that you have bad breath?

Yes

May be / Not sure

10. Are there any growths or sore spots in your mouth?

Yes

Not sure / May be

11. Have you ever been in a vehicle accident or experienced any blows to your jaw?

Yes

May be / Not sure

12. Have you ever had any implant surgery in one or both of your jaws or jaw joints? If yes, please provide: who performed the surgery

Surgery Date

Yes

Not sure / May be

13. Are you being followed-up by dental specialists? If yes, please provide names of the specialists

Yes

May be / Not sure

14. Please list anything else not mentioned above regarding your past dental history.

15. What do you look for most in a dentist/dental office?

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for my dental care. I understand that responsibility for payment for the dental services for myself or my dependents is mine, and I will assume responsibility for fees associated with these services. Should there be any changes in either my health or personal information, I will advise the dentist and patient coordinator.