Patient History

PATIENT NAME Date
Primary reason for this dental appointment:
Email

Dental History

 Please Select
Do you have a specific dental problem? Describe
Do you have dental examinations on a routine basis?
Last visit
Do you have frequent headaches?
Do you brush and floss on a routine basis? Discuss
Do your gums ever bleed? Discuss
Do you like your smile? Why?
Does food catch between your teeth? Any loose teeth?
Do you want to keep your remaining teeth?
Do you ever have clicking, popping discomfort in the jaw joint? Do you brux or grind?
Have your past experiences in a dental office always been positive?
Do you smoke or chew? Any sores or growths in your mouth? Discuss
Are there any fears we need to be made aware of?
Name of Previous dentist (Optional) :
Date of last full mouth x-rays (16 small films or panoramic) :

Medical History
Are you under a physician's care now? Why?
Who? Phone
Have you ever been hospitalized or had a major operation? Discuss
Have you ever had a serious injury to your head or neck? Discuss
Are you taking any medications, pills or drugs? What?
Are you on a special diet? Discuss
Are you allergic to any medications or substances? Please check box below
Women (Please check):
What trimester?
Do you now have or have you ever had any of the following? Please check appropriate boxes.
*if yes to any of the starred conditions, please call prior to your appointment… premedication may be required.
Yes No
Anemia*
Arthritis*
Artificial Heart Valve*
Asthma*
Cancer*
Cold Sores/Fever Blisters*
Dizziness*
Emphysema*
Excessive Bleeding*
Fainting*
Head Injuries*
Heart Murmur*
Hepatitis A, B or C*
High Blood Pressure*
Yes No
Kidney Disease*
Latex Sensitivity*
Pacemaker*
Radiation Treatment*
Respiratory Problems*
Sinus Problems*
Smoke/Chew Tobacco*
Stroke*
Thyroid Problems*
Tumors*
Ulcers*
Codeine Allergy*
Penicillin Allergy*

Allergic/Adverse reaction to medication or any substance If so, what?
Have you ever had any other serious illness not checked above? Discuss
Do you wish to talk to the dentist privately about any problem?
Any other serious illness/condition not listed above? Discuss

To the best of my knowledge, all the preceding answers are correct. If I have any changes in my health status or if my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without fail.
Reviewed By Doctor Date: BP
History Review and Significant Findings

Medical Updates
I have read my MEDICAL HISTORY dated and confirm that it adequately states past and present conditions.

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