MEDICAL HISTORY

"*" indicates required fields

FIRST NAME*

LAST NAME*

DATE OF BIRTH*

MM slash DD slash YYYY

IN CASE OF EMERGENCY, CONTACT NAME*

PHONE*

1. ARE YOU BEING TREATED FOR ANY MEDICAL CONDITION AT THE PRESENT OR HAVE BEEN TREATED WITHIN THE PAST YEAR?

Yes

Not sure/May be

IF SO, WHY?

2. WHEN WAS YOUR LAST MEDICAL CHECKUP?

MM slash DD slash YYYY

3. HAS THERE BEEN ANY CHANGE IN YOUR GENERAL HEALTH IN THE PAST YEAR?*

Yes

Not sure/May be

IF YES, PLEASE EXPLAIN.

4. ARE YOU TAKING ANY MEDICATIONS, NON-PRESCRIPTION DRUGS OR HERBAL SUPPLEMENTS OF ANY KIND?*

Yes

Not sure/May be

IF YES, PLEASE LIST (INCL. NAMES & DOSAGES).

5. DO YOU HAVE ANY ALLERGIES?*

Yes

Not sure/May be

IF YES, PLEASE LIST USING THE CATEGORIES: a) MEDICATION b) LATEX/RUBBER PRODUCTS c) OTHER e.g. HAYFEVER, FOODS

6. HAVE YOU EVER HAD A PECULIAR OR ADVERSE REACTION TO ANY MEDICINES OR INJECTION?*

Yes

Not sure/May be

IF YES, PLEASE EXPLAIN.

7. DO YOU HAVE OR HAVE YOU EVER HAD ASTHMA?*

Yes

Not sure/May be

8. DO YOU HAVE OR HAVE YOU EVER HAD ANY HEART OR BLOOD PRESSURE PROBLEMS?*

Yes

Not sure/May be

9. DO YOU HAVE OR HAVE YOU EVER HAD A HEART MURMUR, MITRAL VALVE PROLAPSE OR RHEMATIC FEVER?*

Yes

Not sure/May be

10. DO YOU HAVE A PROSTHETIC OR ARTIFICIAL JOINT?*

Yes

Not sure/May be

11. HAVE YOU EVER BEEN ADVISED BY YOUR DOCTOR/DENTIST TO TAKE ANTIBIOTICS BEFORE DENTAL TREATMENT?*

Yes

Not sure/May be

12. DO YOU HAVE ANY CONDITIONS OR THERAPIES THAT COULD EFFECT YOUR IMMUNE SYSTEM e.g. LEUKEMIA, AIDS, HIV INFECTION, RADIOTHERAPY, AND CHEMOTHERAPY?*

Yes

Not sure/May be

13. HAVE YOU EVER HAD HEPATITIS, JAUNDICE OR LIVER DISEASE?*

Yes

Not sure/May be

14. DO YOU HAVE A BLEEDING PROBLEM OR BLEEDING DISORDER?*

Yes

Not sure/May be

15. HAVE YOU EVER BEEN HOSPITALIZED FOR ANY ILLNESS OR OPERATIONS?*

Yes

Not sure/May be

IF YES, PLEASE EXPLAIN.

16. DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? PLEASE CHECK.*

CHEST PAIN, ANGINA

SHORTNESS OF BREATH

CANCER

STEROID THERAPY

SEIZURES (EPILEPSY)

HEART ATTACK

PROSTHETIC HEART VALVE

LUNG DISEASE

DIABETES

KIDNEY DISEASE

STROKE

PACEMAKER

TUBERCULOSIS

STOMACH ULCERS

THYROID DISEASE

DRUG OR ALCOHOL DEPENDENCY

ARTHRITIS

DIET PILL THERAPY

NONE OF THESE

17. ARE THERE ANY CONDITIONS OR DISEASES NOT LISTED ABOVE THAT YOU HAVE OR HAVE HAD? IF YES, PLEASE LIST.*

Yes

Not sure/May be

IF YES, PLEASE LIST.

18. ARE THERE ANY DISEASES OR MEDICAL PROBLEMS THAT RUN IN YOUR FAMILY? (e.g. DIABETES, CANCER OR HEART DISEASE)*

Yes

Not sure/May be

IF YES, PLEASE LIST.

19. DO YOU SMOKE OR CHEW TOBACCO PRODUCTS?*

Yes

Not sure/May be

20. DO YOU USE CANNABIS/MARIJUANNA? IF SO, HOW FREQUENTLY?*

Yes

Not sure/May be

IF SO, HOW FREQUENTLY?

21. ARE YOU NERVOUS DURING DENTAL TREATMENT?*

Yes

Not sure/May be

22. FOR WOMEN ONLY: ARE YOU BREAST-FEEDING OR PREGNANT?*

Yes

Not sure/May be

IF PREGNANT, WHAT IS THE EXPECTED DELIVERY DATE?*

MM slash DD slash YYYY

DENTAL HISTORY

1. WHEN WAS YOUR LAST DENTAL VISIT?

MM slash DD slash YYYY

2. WHEN DID YOU LAST HAVE DENTAL X-RAYS?

MM slash DD slash YYYY

3. HOW OFTEN DO YOU BRUSH YOUR TEETH?

4. HOW OFTEN DO YOU FLOSS YOUR TEETH?

5. HAVE YOU BEEN SEEING A DENTIST REGULARLY?*

Yes

Not sure/May be

6. DO ANY OF YOUR TEETH ACHE?*

Yes

Not sure/May be

7. DO YOUR GUMS BLEED WHEN YOU BRUSH?*

Yes

Not sure/May be

8. DO YOU HAVE ANY PAIN WHEN YOU CHEW?*

Yes

Not sure/May be

9. DO YOU FEEL THAT YOU HAVE BAD BREATH?*

Yes

Not sure/May be

10. ARE THERE ANY GROWTH'S OR SORE SPOTS IN YOUR MOUTH?*

Yes

Not sure/May be

11. HAVE YOU EVER BEEN IN A VEHICLE ACCIDENT OR EXPERIENCED ANY BLOWS TO YOUR JAW?*

Yes

Not sure/May be

12. HAVE YOU EVER HAD ANY IMPLANT SURGERY IN ONE OR BOTH OF YOUR JAWS OR JAW JOINTS?*

Yes

Not sure/May be

IF YES, PLEASE PROVIDE: WHO PERFORMED THE SURGERY?

SURGERY DATE

MM slash DD slash YYYY

13. ARE YOU BEING FOLLOWED-UP BY DENTAL SPECIALISTS?*

Yes

Not sure/May be

IF YES, PLEASE PROVIDE THE NAMES OF THE SPECIALISTS:

14. PLEASE LIST ANYTHING ELSE NOT MENTIONED ABOVE REGARDING YOUR PAST DENTAL HISTORY.

15.WHAT DO YOU LOOK FOR MOST IN A DENTIST/DENTAL OFFICE?

GENERAL RELEASE

I AGREE*

I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information.

I AGREE*

I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary.

I AGREE*

I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for my dental care.

I AGREE*

I understand that responsibility for payment for the dental services for myself or my dependents is mine, and I will assume responsibility for fees associated with these services.

I AGREE*

Should there be any changes in either my health or personal information, I will advise the dentist and patient coordinator.

Signature (to be signed at office)

Signed Date

Professional Affiliations and Recognitions