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Medical History
Is your general health good? □YES NO If NO, please explain: _____________________________________
__________________________________________________________________________________________
Has there been a change in your health in the last year? □YES NO If YES, please explain: _______________
__________________________________________________________________________________________
Physician's Name: ____________________ Phone Number: _________________ Receiving Care? □YES NO
Please explain: _______________________________________________________________________ __________________________________________________________________________________________
Have you ever had or do you currently have any of the following conditions?
Yes
□ Do you use tobacco? If YES, in what form and how much? _________________________________
Have you ever taken a Bisphosphonate (Fosamax, Actonel, Boniva, Reclast, Didronel, Zometa, Skelid) or
osteoclast inhibitor drug (Prolia)? □Yes NO If YES, how long ago and how taken? _____________________
Are you allergic or have you reacted adversely to any of the following? (please circle): Penicillin / Latex / Sulfa
Drugs / Local anesthetic (Novocain) / Other Allergies: _____________________________________________
For Female Patients
Yes
□ Are you currently taking oral contraceptives (antibiotics may decrease effectiveness)
Any other medical conditions, please describe: ____________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please list drugs and supplements you are taking right now and state for what condition? (include prescription,
over the counter, and recreational) example: Prilosec for acid reflux: __________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
The practice of dentistry involves treating the whole person. If the dentist determines that there may be a potential medically compromised
situation, medical consultation may be needed prior to commencement of dental treatment. I authorize the dentist to contact my physician. I
have read and understand this form. To the best of my knowledge, I have answered every question completely and accurately. I will inform
my dentist of any change in my health and/or medication. I will not hold my dentist, or any other member of his/her staff, responsible for
any errors or omissions that I may have made in the completion of this form.
Signature of Patient (parent or guardian_____________________________________________________ Date___________________________

Dental History
Has a physician or dentist ever recommended you take antibiotics before dental treatment? □YES NO If YES,
please explain: _____________________________________________________________________________
How can we help you today? __________________________________________________________________
__________________________________________________________________________________________
Who was your last dentist? _______________________________ Location? ___________________________
Why did you decide to change dentists? _________________________________________________________
When was the last time; you saw a dentist? __________ X-rays? _________ Professional Cleaning? _________
Have you ever had an unpleasant dental experience?) □YES NO If YES, please describe, we want to make
sure it doesn’t happen again! __________________________________________________________________
__________________________________________________________________________________________
How is your current dental health? □Good □Average □Needs improvement □Not sure
Do your gums bleed when you brush or floss? □Never □Sometimes □Almost every time
Do you feel you will eventually wear artificial dentures? □YES □NO
Are you concerned about the finances required to achieve excellent dental health? □YES □NO
Any jaw problems? □Pain □Clicking/Joint Noise □Difficulty opening/closing □History of TMD □NONE
Do you Grind or Clench? □YES □NO
Do you get frequent migraines/headaches? □YES □NO Have you been diagnosed with Sleep Apnea? □YES □NO If YES, do you wear a CPAP? □YES □NO If you wear a CPAP, are you comfortable with it? □YES □NO Are you interested in cosmetic options? □YES □NO If yes, please describe: ___________________________
__________________________________________________________________________________________
Are your teeth sensitive to (please circle) cold / hot / sweets / biting? If so, please explain (where/when): ____
__________________________________________________________________________________________
Does dental treatment make you nervous? □YES □NO
Are you interested in our relaxation methods to ease dental anxiety or get more work done in fewer appointments such as (please circle) Nitrous Oxide (laughing gas) or Conscious Sedation (oral or IV sedation medicine) Any other concerns? ________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Source: http://dentistrybydesignks.com/wp-content/uploads/forms/2014/Medical-and-Dental-History.pdf

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