Patient Medical & Dental History Form

Patient Medical History

Are you under medical treatment right now?

Checkbox Description

Have you been hospitalized for any surgical operation or serious illness within the last 5 years?

Are you takin any medication(s) including non-prescription medicine?

Have you ever taken Fen-Phen/Redux?

Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates?

Have you ever taken Viagra, Revatio, Cialis, or Levitra in the last 24 hours?

Do you use tobacco?

Do you use controlled substances?

Are you wearing contact lenses?

Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?

Women Only:

Are you pregnant or think you may be pregnant?

Are you nursing?

Are you taking oral contraceptives?

Patient Dental History

Address of Previous Dentist

Country

State/Province

Do your gums bleed while brushing or flossing?

Are your teeth sensitive to hot or cold liquids/foods?

Are your teeth sensitive to sweet or sour liquids or foods?

Do you feel pain in any of your teeth?

Do your have any sores or lumps in or near your mouth?

Have you had any head, neck, or jaw injuries?

Have you ever experienced any of the following problems in your jaw?

Please check all that apply

Clicking
Pain (joint, ear, side of face)
Difficulty opening or closing

Do you have frequent headaches?

Do you clench or grind your teeth?

Do you bite your lips or cheeks frequently?

Have you ever had any difficult extractions in the past?

Have you ever had any prolonged bleeding following an extraction?

Have you had any orthodontic treatment?

Do you wear dentures or partials?

Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

Do you like your smile?

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners.

To accept the Terms of Authorization & Release please sign below.

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Patient Medical & Dental History Form

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