MEDICAL & DENTAL HISTORY
Name__________________________________________________ Date of Birth_________________
Address______________________________________________________________________________
Phone: Home ___________Cell ___________ Work ___________e-mail__________________________
Employer/School_________________________________ Occupation ___________________________
Family Physician_____________________ Phone___________ Date of last check-up _______________
In Case of Emergency Notify_____________________ Phone ___________ Relationship ____________
Who may we thank for referring you ______________________________________________________
Have you ever been hospitalized for any illness or operations? __________________________________
_____________________________________________________________________________________
Do you have or have you ever had any of the following?
Please underline all that apply
Heart murmur/Mitral valve prolapse
Stomach/Intestinal problems/Ulcers
Steroid/Cortisone therapy
Joint replacements
Hepatitis A or B or C
Chest pain/Angina/ Hearth attack
Rheumatic/ Scarlet fever
HIV/ AIDS
Bleeding problem/disorder
Asthma
Diabetes I or II
Liver disease
Thyroid disease
Stroke
Tuberculosis
Kidney disease
Organ transplant
Eating disorder
Epilepsy seizures
High blood pressure
Cancer
Arthritis
Shortness of breath
Prosthetic heart valve
Kidney problems
Drug/Alcohol addiction
Have you or are you being treated for any medical conditions not listed above? Please specify ________
_____________________________________________________________________________________
List any prescription, over the counter or herbal medication you are taking. _______________________
_____________________________________________________________________________________
Do you have any allergies? Please specify___________________________________________________
Do you require antibiotics before dental treatment? __________
WOMEN ONLY: Are you pregnant? If yes, when is your due date? __________________________
Are you nursing? Yes or No
Are you taking birth control pills? Yes or No
Have you ever had any of the following?
Please Circle all that apply
Braces/Invisalign
Oral Surgery
Gum surgery
Night guard
Root Canal
Implants
Whitening
Cold Sores
Do your gums bleed easily? Yes or No
Do your gums feel tender or swollen? Yes or No
Do you clench or grind your teeth? Yes or No
Are your teeth sensitive to?
Please circle all that apply
Hot
Cold
Biting
Sweets
How happy are you with your smile from 1 to 10? _________________________________
What would you change about your smile? ______________________________________
Patient’s (Parent’s) Signature_______________________________ Date____________