MEDICAL/DENTAL HISTORY

Email Address*

Please Check Any Past or Present Conditions:*

Artificial Joint Replacement/Pins/Prosthesis

Rheumatic Fever

Artificial Heart Valve

Pacemaker

Heart Murmur

Cardiac Bypass Surgery

Other Heart Problems

Prescription Weight Loss Products (Fen-phen, Redux, Pondimen)

High Blood Pressure

Acquired Immune Deficiency Syndrome (AIDS)

HIV Positive

An unusual reaction to Dental Anesthesia (Gas or Shots)

Diabetes

Radiation Therapy

Psychiatric or Emotional Problems

Pregnancy at this time

Nursing

Frequent Headaches

Allergy to Penicillin

Codeine Intolerance

Aspirin Intolerance

Other Medication Intolerance

Sensitivity to Metals or Latex

Drug or Alcohol Addiction

Habitual use of Controlled Substances

Periodontal Disease (Gum Disease, Pyorrhea, Trench Mouth)

Stroke

Asthma

Fainting Spells or Epilepsy

Anemia or Blood Problems

Excessive Bleeding

Daily Aspirin Intake

Kidney Problems

Hepatitis or Liver Problems

Venereal Disease

Mouth or Jaw Injury

Grind or Clench Your Teeth

Sinus Problems

Bad Breath

None

Pre-medication prior to Dental Appts*

Has a Doctor ever recommended that you take pre-medication prior to dental appointments?

Yes

No

Gum Bleeding*

Do your gums bleed while brushing or flossing your teeth?

Yes

No

Pain in Teeth/Gums while brushing*

Do you feel pain from any teeth or gums when brushing or flossing?

Yes

No

Orthodontic treatment*

Have you ever had orthodontic treatment (teeth straightened)?

Yes

No

Sensitivity*

Are any of your teeth sensitive to cold, heat, sweets, or pressure?

Yes

No

Smoking*

Do you smoke cigarettes, cigars, pipe, or chew tobacco?

Yes

No

Dental Visit Experience*

Has fear of discomfort kept you from regular dental visits or have you experienced any unfavorable dental experiences?

Yes

No

Privacy*

Would you like to speak to the Doctor privately about any problem?

Yes

No

Toothbrush

What type of toothbrush do you use and what firmness?

Last teeth cleaned on

When was the last time you had your teeth cleaned by a dentist?

Frequency of brushing teeth*

How often do you brush your teeth?

Current Drugs or Medication*

List any drugs or medications you are now taking:

Existing Medical problems*

Please list any other medical problems that the Doctor should be aware of:

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