Medical and Dental History Patient Name_____________________________________ Date of Birth_______________ Please fill out the form completely to the best of your ability. Health problems that you may have, or medication(s) that you may be taking may have an important interrelationship with the dental care you receive. Thank you.
Name of Primary care physician __________________________________________ Phone: (____)_____-___________
Address/Location of Primary care Physician:______________________________________________________________ List any prior Hospitalizations or surgeries including the year and reason for hospitalization or surgery: ______________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Have you ever had a serious head or neck injury? If yes, explain:_______________________________________________________ Please list any medication(s) you are currently taking, including dosage and frequency: ______________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Do you take, or have you taken Phen-Fen, Redux, Bonivia, Fosamax, Actonel, Didronel, Shelid, Aredia, Zometa? (please circle) Are you on a special diet? If yes, explain:__________________________________________________________________________ Do you use tobacco? If yes, how much and how often?__________________________________ Smoke or smokeless (please circle) Do you use controlled substances? If yes, please name and include the dosage and frequency:________________________________ Have you ever had prolonged or unusual bleeding? If yes, explain:______________________________________________________ Women Only: Are you □ Pregnant/Trying to get pregnant? □ Nursing? □ Taking Oral Contraceptives? Are you allergic to any of the following? □ Aspirin □ Penicillin □ Codeine □ Acrylic □ Metal □ Latex □ Local Anesthetics □ Other: ________________________________________ Please explain the reaction ______________________________________ Do you have, or have you had, any of the following? □ AIDS/HIV positive
□ Artificial Heart Valve □ Drug Addiction
□ Heart Trouble/Disease □ Pain in Jaw Joints
□ Radiation Treatments □ Tuberculosis
Have you ever had a serious illness not listed above? If yes, please explain: _________________________________________________ Have you ever had a reaction to local anesthetic? If yes, please explain: ___________________________________________________ Have you ever had complications or illness following dental treatment? If yes, please explain: ________________________________ Are you currently in any pain? If yes, please explain: _________________________________________________________________ When was your last dental checkup? ______________ Last dental cleaning? ________________ X-Rays? _________________________ What is the name of your previous Dentist? __________________________________Address/Location: __________________________ Have you ever been treated for Active Periodontal Disease? If yes, how long ago? ___________________________________________ How often do you brush? _________________ How often do you floss? ____________________ If you could change anything at all about your smile, what would it be? _____________________________________________________ ______________________________________________________________________________________________________________ To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or the patient’s) health. It is my responsibility to inform the dental office of any changes in medical status. If I ever have any change in my health condition or the medications I take, I will inform the Doctor on my next appointment.
Signature of Patient, Parent, or Guardian: ______________________________________________________ Date: _______________
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