Patient History
Patient Name :
First Name
Middle Name
Last Name
Do you have regular medical checkups?
Yes
No
Are you under the care of a physician now?
Yes
No
Reason :
Have you ever had a serious head injury?
Yes
No
Explain :
Have you taken either oral or IV bisphosphonates?
Yes
No
Explain :
Are you allergic to any other substances?
Yes
No
Explain :
Are you taking any medications/supplements?
Yes
No
If yes, please list below
Do you now or have you ever had any of the following?
Heart Disease/ Disorder -
Heart Attack/ Failure
Irregular Heart Beat
Mitral Valve Prolapse
Artificial Heart Valve
Heart Surgery/ Stent
Angina/ Chest Pain
Heart Murmur/ Rheumatic Fever
Bacterial Endocarditis
Pacemaker/ Defibrillator
Lung Disease/ Disorder -
Tuberculosis
Asthma/ Emphysema
Persistent Cough
Sinus Problem/ Allergy
Reheumatism/ Arthrtis -
Osteoporosis
Artificial Joint
Cortisone Treatment
Kidney Disease/ Disorder -
Renal Failure/ Dialysis
Cold Sores/ Fever Blisters -
Hives or Rash
Venereal Disease/ Genital Herpes
HIV Positive/ AIDS
Liver Disease/ Disorder -
Hepatitis A, B, C, Other
Diabetes or Family History
Excessive Thirst/ Urination
Neurological Disease/ Disorder -
Epilepsy/ Seizures
Fainting/ Dizziness
Digestive Disorder/ Reflux -
Ulcers/ Diarrhea
Recent Weight Loss/ Gain
Colon Disease/ Disorder
Thyroid/ Parathyroid Disease
Cancer / Tumors -
Chemotherapy/ Radiation
Psychiatric Care
Drug Addition/ Alcoholism
Alzheimers/ Demetia
Circulatory Disorders -
Stroke
Swelling of Limbs
Bruise Easily/Anemia
Blood Disease
Blood Transfusion
Bleeding Disorder
High/Low Blood Pressure
Do you have any health issues not listed above?
Women - Are you pregnant, think you may be pregnant or currently nursing?
Yes
No
Have you ever been told you needed to take antibiotics before a dental procedure?
Yes
No
If yes, Why?
*
To the best of my knowledge, all preceding answers are correct. If I have any changes in my health status or medications, I shall inform the dentist and/or staff at the next appointment.
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These Questions will help you identify and communicate to us important personal issues with respect to your dental goals.
1. Why are you coming to see us?
2. What is important to you about your teeth?
3. How would you describe the present condition of your mouth?
4. How do you feel about the appearance of your smile?
5. How do you see your teeth 20 years from now?
6. What has kept you from going ahead with the dentistry you want?
7. What quality of dentistry are you looking for?
8. Describe your ideal dental office/ provider
9. What else would you like us to know about you?
Signature:
*
(Your digital signature (full name) is as legally binding as a physical signature.)
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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