Medical and Dental History

Medical & Dental History Form

First Name

Middle Initials

Last Name

Preferred Name

Please take a moment to let us know about your medical and dental history so we may serve you more effectively and in a way that watches out for your overall health and well-being.

Would you consider yourself to be in fairly good health?
Yes
No
Within the past year, have there been any changes in your general health?
Yes
No
What is the date (or approximate date) of your last medical exam?

Your Primary Care Physician’s name, address, & phone number:

Please mark any of the following to indicate Yes in response to the question:
Have you ever had complications following dental treatment?
Are you currently under the care of a physician due to a specific condition?
Have you been hospitalized within the last 5 years due to a surgery or illness?
Are you currently taking any prescription or non-prescription medications?
Do you use tobacco (smoking or chewing)?
Do you require the use of corrective lenses (contacts or glasses)?
Do you have any other conditions, diseases, etc., not listed above that we should be aware of?
If any of the previous questions are marked, please explain:

WOMEN ONLY: Are you pregnant?
Yes
No
If Yes, when is the due date?

Please indicate if you have experienced any of the following:

*Pre-Med – Amox
*Pre-Med – Clind
*Pre-Med – Other
Allergies
Allergy – Aspirin
Allergy – Codeine
Allergy – Erythro
Allergy – Hay Fever
Allergy – Latex
Allergy – Other
Allergy – Penicillin
Allergy – Sulfa
Anemia
Arthritis
Artificial Joints
Asthma
Blood Disease
Cancer
Diabetes
Dizziness
Epilepsy
Excessive Bleeding
Fainting
Glaucoma
Head Injuries
Heart Disease
Heart Murmur
Hepatitis
High Blood Pressure
HIV
Jaundice
Kidney Disease
Liver Disease
Mental Disorders
Nervous Disorders
Other
Pacemaker
Pregnancy
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Rheumatism
Sinus Problems
Stomach Problems
Stroke
Tuberculosis
Tumors
Ulcers
Venereal Disease
Do you have any other health issues or allergies?

What is the reason for your dental visit today?

When was your last visit to the dentist (if to a different office)?

What was done on your last dental visit (if to a different office)?

Prior Dentist’s name, address, & phone number:

How frequently do you brush your teeth?
3 (+) a day
Twice a day
Once a day
Weekly
Seldom
How frequently do you floss your teeth?
1 (+) a day
2 – 6 weekly
1 – 6 monthly
Seldom
Never
Please mark any of the following to indicate Yes in response to the question:
Do your gums bleed when you brush or floss?
Do your teeth experience sensitivity to cold or hot temperatures?
Are any of your teeth currently causing you pain?
Do you grind your teeth (either consciously or during sleep)?
Are any of your teeth loose, or are you concerned about any teeth loosening?
Do you currently have any dental implants, dentures, or partials?
If any of the previous questions are marked, please explain:

If you could change anything about your mouth, teeth, or smile, what would it be?

To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health, I will inform the office at my next detal appointment without fail.

Authorization

I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize the payment from my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on behalf of my dependents (if any).

Signature of patient, parent, or guardian:

Relationship to Patient:


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