Patient Medical/Dental History Form NAME:__________________________________ DATE:__________________
MEDICAL HISTORY HAVE YOU HAD:
NO YES Are you in good general health?
Are you now taking any drugs or medications?
“yellow Jaundice”, Hepatitis problems
Broken bones of the face, neck, jaw or back
YES Would you object to our office contacting your
family doctor in regard to any medical problem
Any medical treatment for nervous condition
(Novocaine or Xylocaine) by a dentist or doctor?
Have you ever received general anesthesia?
Have you ever had any adverse reaction to either
A gain or loss of more than 15 pounds in your
Do you take vitamins containing Vitamin E?
Do you take aspirin products or anti-inflammatory
Other:_________________________________________
PLEASE LIST ALL PREVIOUS SURGERIES AND DATES:
Have dentures, false teeth, caps or bridges
__________________________________________________
_________________________________________________
DO ANY FAMILY MEMBERS HAVE: (Circle if yes)
Have any contagious or infectious condition
Have you been exposed directly or indirectly
The above information is strictly confidential Patient Medical/Dental History Form PATIENT DENTAL HISTORY
What is your reason for seeking care at this time: ______________________________________________________________
Do you have regular dental checkups? When was your last dental exam: _________________________________________ Have you had any dental x-rays completed within the last 5 years:________________________________________________
Do you have any pain or discomfort now? What: _______________________________________________________________ Do your gums bleed? ______________________ Have you had surgery preformed on your gums? ___________________
Have you ever had a root canal? ____________ Have you ever worn braces? ___________ Do you wear Dentures?_____ Do you grind your teeth?____________ Have you ever had any trauma to your face or mouth? _______________________ Do you floss? How often _______________ How many times a day do you brush your teeth? _________________________ 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 also understand that I am responsible for any account balance and payment in full is expected at time of service, unless prior arrangements have been made. As a courtesy to our patients, your insurance claims will be completed for you. However, Insurance is between you and your
insurance company. You are still responsible for any unpaid or denied claims. All information is HIPPA compliant and will only be disclosed for medical or dental treatment. __________________________________________________________ Date: _________________________________________ Signature of Patient/Parent or Guardian