Form 2 of 3
Patient Name
*
First
Middle
Last
Medical History
Physician’s Name
Telephone #
Date of Last Exam
Date Format: MM slash DD slash YYYY
Are you under medical treatment now?
Yes
No
Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
Yes
No
If yes, please explain
Are you taking any medication(s) including non-prescription medicine?
Yes
No
If yes, what medication(s) are you taking?
Have you ever taken Fen-Phen/Redux?
Yes
No
Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates?
Yes
No
Have you taken Viagra, Revatio, Cialis or Levitra in the last 24 hours?
Yes
No
Do you use tobacco?
Yes
No
Do you use controlled substances?
Yes
No
Are you wearing contact lenses?
Yes
No
Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?
Yes
No
For women : Are you pregnant or think you may be pregnant?
Yes
No
For women : Are you nursing?
Yes
No
For women : Are you taking oral contraceptives?
Yes
No
Do you have or have you had any of the following?
High Blood Pressure
Rheumatic Fever
Fainting / Seizures
Low Blood Pressure
Leukemia
Kidney Diseases
Thyroid Problem
Heart Disease
Cardiac Pacemaker
Heart Murmur
Angina
Frequently Tired
Aemia
Emphysema
Cancer
Arthritis
Joint Replacement or Implant
Hepatitis /Jaundice
Sexually Transmitted Disease
Stomach Troubles / Ulcers
Chest Pains
Easily Winded
Stroke
Hay Fever / Allergies
Tuberculosis
Radiation Therapy
Glaucoma
Recent Weight Loss
Liver Disease
Heart Trouble
Respiratory Problems
Heart Attack
Swollen Ankles
Asthma
Epilepsy / Convulsions
Diabetes
Are you allergic to or have you had any reactions to the following?
Local Anesthetics (e.g. Novocain)
Penicillin
Any other Antibiotics
Sulfa Drugs
Barbiturate
Sedatives
Iodine
Aspirin
Latex Rubber
Any Metals (e.g. nickel, mercury, etc.)
Dental history
Previous dentist's name
Dentist phone #
Dentist address
Street Address
City
State / Province / Region
ZIP / Postal Code
Date of Last Exam
Date Format: MM slash DD slash YYYY
Do your gums bleed while brushing or flossing?
Yes
No
Are your teeth sensitive to hot or cold liquids/foods?
Yes
No
Are your teeth sensitive to sweet or sour liquids/foods?
Yes
No
Do you feel pain to any of your teeth?
Yes
No
Do you have any sores or lumps in or near your mouth?
Yes
No
Have you had any head, neck or jaw injuries?
Yes
No
Do you have frequent headaches?
Yes
No
Do you clench or grind your teeth?
Yes
No
Do you bite your lips or cheeks frequently?
Yes
No
Have you ever had any difficult extractions in the past?
Yes
No
Have you ever had any prolonged bleeding following extractions?
Yes
No
Have you had any orthodontic treatment?
Yes
No
Do you wear dentures or partials?
Yes
No
If yes, date of placement
Have you ever received oral hygiene instructions regarding the care of your teeth and gums?
Yes
No
Do you like your smile?
Yes
No
Have you ever experienced any of the following problems in your jaw?
Clicking
Difficulty in opening or closing
Pain (joint, ear; side of face)
Difficulty in chewing
Authorization and Release
Consent
*
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. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for s ervices. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
Signature
*
(Your digital signature (full name) is as legally binding as a physical signature.)
Date
Date Format: MM slash DD slash YYYY