Patient Medical and Dental History Form Patient's Name First Middle Last Phone NumberPreferred Name 1. Are you under a physician’s care? Yes No 2. Have you ever been hospitalized for any surgical operations or serious illness? Yes No If yes to being hospitalized, please explain3. Are you taking any medication including non-prescription medicine? Yes No If yes to taking medication(s), please list your medication(s) below4. Are you currently taking or have you ever taken osteoporosis medications in the past? Yes No If yes to taking osteoporosis medications, how long and which ones?5. Do you use tobacco products? Yes No 6. Do you use controlled substances? Or recreational drugs? Yes No 7. Please check if you are allergic to any of the following: Local Anesthetics (e.g. lidocaine) Penicillin Sulfa Drugs Sedatives Iodine Aspirin Ibuprofen Tylenol Codeine Any Metals (e.g. nickel, mercury, etc.) Latex rubber Other None If checked "other", please tell us what you are allergic to here: 8. Women Only (Check if any of the following are true): a) Are you pregnant or think you may be pregnant? b) Are you Nursing? c) Are you taking oral contraceptives? 9. If you have any of the following medical conditions, please check below: High Blood Pressure Heart Attack / Failure Rheumatic Fever Swelling of Limbs Fainting Spells / Vertigo Excessive Bleeding Anaphylaxis Low Blood Pressure Epilepsy / Seizures Cancer Radiation Therapy Diabetes Kidney Diseases AIDS or HIV Infection Thyroid Problem Hearing Impaired Heart Disease Mitral Valve Prolapse Cardiac Pacemaker Heart Murmur Irregular Heartbeat Angina Frequently Tired Anemia Emphysema / COPD Tuberculosis Asthma Arthritis / Gout Joint Replacement or Implant Hepatitis / Jaundice Sexually Transmitted Disease Stomach Troubles / Ulcers Cold Sores / Fever Blisters Frequent Cough Neck / Back Pains Chest Pains Easily Winded Stroke Hay Fever / Allergies Hives or Rash Glaucoma Recent Weight Loss Liver Disease High Cholesterol Other None If checked "other", please tell us what condition you have here: Patient Dental History Name of Previous Dentist/Location Date of Last Exam/Cleaning Month Day Year 1. Do your gums bleed while brushing or flossing? Yes No 2. Are your teeth sensitive to hot or cold liquids/foods? Yes No 3. Are your teeth sensitive to sweet or sour liquids/foods? Yes No 4. Do you feel pain in any of your teeth? Yes No 5. Do you have any sores or lumps in or near your mouth? Yes No 6. Have you had any head, neck or jaw injuries? Yes No 7. Have you ever experienced any of the following problems in your jaw? Clicking Pain (joint, ear, side of face) Difficulty in opening or closing Difficulty in chewing None of the above 8. Do you have frequent headaches? Yes No 9. Do you clench or grind your teeth? Yes No 10. Do you bite your lips or cheeks frequently? Yes No 11. Have you ever had any difficult extractions in the past? Yes No 12. . Have you ever had any prolonged bleeding following extractions? Yes No 13. Have you ever had any orthodontic treatments? Yes No 14. Do you ever wear dentures or partials? Yes No If yes to wearing dentures/partials, date of placement: DD slash MM slash YYYY 15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums? Yes No 16. Do you like your smile? Yes No Signature*"I certify that the above information is complete and accurate"
