Patient Medical and Dental History Form Patient's Name First Middle Last Preferred Name1. Are you under a physician’s care?YesNo2. Have you ever been hospitalized for any surgical operations or serious illness?YesNoIf yes to being hospitalized, please explain3. Are you taking any medication including non-prescription medicine?YesNoIf 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?YesNoIf yes to taking osteoporosis medications, how long and which ones?5. Do you use tobacco products?YesNo6. Do you use controlled substances? Or recreational drugs?YesNo7. 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/LocationDate of Last Exam/Cleaning Date Format: DD slash MM slash YYYY 1. Do your gums bleed while brushing or flossing?YesNo2. Are your teeth sensitive to hot or cold liquids/foods?YesNo3. Are your teeth sensitive to sweet or sour liquids/foods?YesNo4. Do you feel pain in any of your teeth?YesNo5. Do you have any sores or lumps in or near your mouth?YesNo6. Have you had any head, neck or jaw injuries?YesNo7. 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?YesNo9. Do you clench or grind your teeth?YesNo10. Do you bite your lips or cheeks frequently?YesNo11. Have you ever had any difficult extractions in the past?YesNo12. . Have you ever had any prolonged bleeding following extractions?YesNo13. Have you ever had any orthodontic treatments?YesNo14. Do you ever wear dentures or partials?YesNoIf yes to wearing dentures/partials, date of placement: Date Format: DD slash MM slash YYYY 15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums?YesNo16. Do you like your smile?YesNoSignature*"I certify that the above information is complete and accurate"
