Dental and Medical History
Date of Birth
Do you floss regularly?
Does gum disease run in your family?
Do you clench or grind your teeth?
Do you have a night guard/bite splint?
Do you have orthodontics/braces?
Do you have popping or clicking in the jaw?
Hay fever or airborne allergies?
Heart disorder, disease?
Hemophilia or blood disorder?
Hepatitis A, B?
Psychiatric or psychological case?
Tuberculosis or lung disease?
Headaches or migraines?
Artificial joints (hip, knee, etc)?
Convulsions or epilepsy?
Dizzy spells or fainting?
Cold sores or fever blisters?
Stomach, intestinal, or colon disorders?
Jaundice or liver disease?
Cortisone or steroid therapy?
High blood pressure?
Possess the HIV or AIDS antibody?
Low blood pressure?
Radiation or Chemotherapy?
Do you have any other disease/condition not listed above?
I, the above-named patient, understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Dental care has my permission to ask the respective health care provider or agency, who may release such information. I will notify this dental care facility of any and all changes in my health or medications. I consent to the performing of dental procedures agreed to be necessary or advisable, including the use of local anesthetics.
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