Medical and Dental History Form

Medical and Dental History Form

Please be thorough and do not leave questions unanswered* Please check all that apply. Thank you!
Medical History
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Are you having pain or discomfort at this time?*

YesNo
Have you been a hospital patient in the last two years?*

YesNo
Are you currently under the care of a physician*

YesNo
Physician's Name

First NameLast Name
Physician's Specialty
Physician's Office Phone

Area CodePhone Number
Are you taking medication at the present time?*

YesNo
If yes, please list the medications and their daily dosages.
Include antidepressants (if applicable) and osteoporosis medications.
Are there any medications that you should be taking, but are not taking?*

YesNo
If yes, please explain.
Do you have a history of drug abuse?*

YesNo
Are you allergic to (i.e.itching, rash, swelling, etc.) or have you ever been made sick by:*

PenicillinAspirinCodeineSulfaAcetaminophenIbuprofenLidocaine (novocaine)None of the above
Have you had any excessive bleeding requiring special treatment?*

YesNo
Do you currently smoke cigarettes, pipes, or cigars?*

YesNo
Do you chew smokeless tobacco?*

YesNo
Do you take any antidepressants?*

YesNo
If yes, which antidepressant?
Do you take over the counter medication or herbal supplements on a regular basis?*

YesNo
If yes, please list:
Do you Snore?*

YesNo
If yes, have you been diagnosed or screened for sleep apnea?

YesNo

Sleep Apnea Screening Questionnaire

	Yes	No
Do you snore loudly? (louder enough to be heard through closed doors or louder than talking)
Do you often feel fatigued, tired or sleepy during the day?
Has anyone observed you stop breathing or choking or gasping during your sleep?
Do you have (or are you being treated for) high blood pressure?
Is your BMI over 35?
Are you over 50 years old?
Is your neck circumference over 17" if you're a male or 16" if you are a female?
Are you a male?

Score 1 point for each positive response.

Scoring interpretation: 0 to 2 = low risk, 3 or 4 = intermedite risk, ≥5 = high risk.

*Ask us about how we can treat sleep apnea with a dental appliance.
The next 5 questions are for WOMEN: Are you pregnant?*

YesNo
If yes, when are you expecting?
Are you being treated for osteoporosis?*

YesNo
If yes, is the medication injected or taken by mouth?

InjectedBy mouth-with foodBy mouth-empty stomach
What is the name of the osteoporosis medication?
Please check any of the following that you have had in the past or currently have:*

Heart failureHeart diseaseHeart attackAngina pectorisHigh blood pressureLow blood pressureHeart murmurRheumatic feverScarlet feverHypertrophic cardiomyopathyHeart pacemakerHeart surgeryAnemiaSickle cell anemiaUlcersStomach diseaseThyroid diseaseDiabetesBulimiaStrokeFainting/Dizzy spellsIntestinal disorderProsthetic Heart ValveMitral valve prolapse (MVP) with regurgitationCongenital Heart MalformationMitral valve prolapse (MVP) without regurgitationPneumoniaEmphisemaTuberculosisAsthmaCOPDSinus troubleAllergies/HivesSyphilis/GonorrheaAlcoholismBenign growthCarcinomaChemotherapyRadiation TherapySclerodermaNervousnessPain in jaw jointsCandida albicansAnorexia nervosaCold soresCanker soresHepatitis AHepatitis BHepatitis CYellow jaundiceBlood transfusionLiver diseaseAnabolic steroidsHemophiliaEpilepsy/SeizuresArthritis/RheumatismPsychiatric treatmentHIV+AIDSKaposi's sarcomaHerpes (oral/genital)LupusKidney troubleBacterial endocarditisNone of the above
Doyou have any disease, condition, or problem not listed?*

YesNo
If yes, please explain.
I understand that several substances including, but not limited to, anabolic steroids, cocaine, excessive alcohol consumption, etc., may have dangerous and even fatal effects when combined with dental anesthetics. I will always disclose any potentially significant information to Dr. Perez, and his team.
Dental History
When did you last visit the dentist?*

3 months or less6 months1 year5 years
What was the purpose of that visit?*

Hygiene visitExamWhiteningCrown/BridgeRoot canalConsultImplantBracesExtractionPain relief
Do you have, or can obtain, a complete set of x-rays or panoramic x-ray taken within the last 15 months?*

YesNoMaybe
If yes, please provide information to help us obtain them:
Do any of your teeth hurt?*

YesNoNot sure
If yes or not sure, please explain.
Are any of your teeth or gum areas sensitive or tender? Please check as many as appropriate.

TeethGumsTenderSensitive
When does this happen?

EatingColdHotSweetsAt night
How often do you experience the sensitivity or pain?

OftenFrequentInfrequentSporadic
Are there any growths or sores in your mouth?*

YesNoMaybe
Do you have any pain or clicking in your jaw joint?*

YesNoSometimes
Do you grind of clench your teeth?*

YesNoNot sure
Are any of your teeth moving or becoming loose?*

YesNoNot sure
Do you catch food in or around any of your teeth and gums?*

YesNo
Do your gums bleed while brushing your teeth?*

YesNo
Do your gums bleed while eating?*

YesNo
Orthodontic treatment*

Never had orthodontic treatmentBracesRetainersInvisalign
Oral surgery

Tooth ExtractionDental ImplantBiopsy
Teeth whitening

In-officeAt-home traysOver the counter product
Periodontal (gums) treatment

ScalingBone/Gum graft
Endodontic treatment

Root canalPulp capAbscess treatmentApicoectomy
Dental Implants. If yes, are you..

SatisfiedDissatisfied
Porcelain veneers

SatisfiedDissatisfied
Bonding

SatisfiedDissatisfied
While having previous dental treatment, have you ever:

FaintedHad an allergic reactionAbnormal or prolonged bleeding

On a scale of 1-10, please rate your smile. *

	1	2	3	4	5	6	7	8	9	10

1 is Can't stand them, 10 is Perfect

How do you feel about the appearance of your teeth?
If you could change your smile, how would you change it?
Do you have any other dental concerns?*

YesNoPossibly
If yes or possibly, please explain.
I fully understand the questions asked on this form. I authorize the release of any information upon the written request of a third party payer or health care practitioner. To the best of my knowledge, all of the preceding answers are true and correct. If I have any changes in my oral health status, I will inform Dr. Perez and his team prior to or at my next appointment.
Full Name*

First NameLast Name
Signature

Clear
Today's Date*

MonthDayYear
Should be Empty:

Medical and Dental History Form

Medical History

Dental History