Dental Medical History
Dental History
Former Dentist:
Date of Last X-rays:
-
Month
-
Day
Year
Date
City/State:
How Often You Floss?
Date of Last Dental Visit:
-
Month
-
Day
Year
Date
How Often Do You Brush?
How Often Do You Brush?
Bad Breath
Loose Teeth
Broken Fillings
Bleeding Gums
Orthodontics Tx
Tooth Sensitivity
Blisters or Bumps
Pain Around Ear
Frequent Headaches
Finger Nail Biting
Periodontic Tx
Head/Neck Injury
Grinding
Extractions
Jaw Difficulty
Lip Cheek Biting
Endodontic Tx
Tooth Pain
Medical History
Physician’s Name:
First Name
Middle Name
Last Name
Date of Last Visit:
-
Month
-
Day
Year
Date
Are you currently under medical treatment?
Yes
No
Have you ever had any serious illnesses or operations?
Yes
No
Are you currently taking any medication?
Yes
No
Do you smoke?
Yes
No
How many times a day?
Do you use recreational drugs (alcohol, cocaine, or other drugs)?
Yes
No
If yes please list and how often:
Do you wear contact lenses?
Yes
No
Have you had any allergic reactions to the following:
Local Anesthetics
Latex
Penicillin/Antibiotics
Sulfa Drugs
Barbiturates
Sedatives
Iodine
Aspirin
Other
[Women only] Are you Pregnant?
Yes
No
[Women only] Are you Nursing?
Yes
No
[Women only] Are you Taking Birth Control Pills or IUD??
Yes
No
Check any and all that apply
AIDS
Fainting/Dizziness
Radiation Treatment
Anemia
Glaucoma
Respiratory Disease
Arthritis, Rheumatism
Headaches
Rheumatic Fever
Allergies, hay fever, sinusitis
Heart murmur
Scarlet Fever
Artificial heart valves
Heart Problems
Shortness of Breath
Asthma
Hepatitis type
Sinus Trouble
Artificial joints
Herpes
Skin Rash
Back Problems
High Blood Pressure
Sickle Cell
Bleeding Abnormalities
Auto Immune Deficiency
Stroke
Blood Disease
Jaundice
Slow Healing
Cancer
Kidney Disease
Swelling of Ankles/Feet
Chemical Dependency
Liver Disease
Swollen Glands
Circulatory problems
Low Blood Pressure
Thyroid Problems
Cortisone treatment
Mitral Valve Prolapse
Tonsillitis
Cough (persistent/bloody)
Osteoporosis/Osteopenia
Tuberculosis
Diabetes
Pacemaker
Tumor Growths
Emphysema
Nervous Problems
Ulcers
Epilepsy
Psychiatric Care
Venereal Disease
Other conditions:
List any medications that you are taking:
Please List any DrugAllergies:
Patient/Guardian Signature:
Date:
-
Month
-
Day
Year
Date
Reviewed by:
Date:
-
Month
-
Day
Year
Date
Submit
Should be Empty: