Medical History

    General Information

    Your Name (required)

    Your Email (required)

    Preferred name

    Reason for visit

    Date of last dental visit/

    Date of last dental x-rays

    Physician Information

    Physician or Clinic Name

    Physician/Clinic Phone or Location

    Pharmacy

    Pharmacy Phone

    Other Information

    How often do you brush?

    How often do you floss?

    Do you smoke or use tobacco products?

    Please list any medication you are now taking
    *It is especially important to know if you are taking bone/osteoporosis medications (Fosamax,Boniva, Prolia, Reclast, or Actonel) tranquilizers, phenobarbital or dilantin, blood thinners (aspirin, Warfarin/Coumadin, Plavix, Xarelto, Eliquis), steroid medicines, nitroglycerin, arthritis or thyroid medicine.

    MaleFemale

    If Female

    Are you taking Birth Control Pills?

    Are you pregnant? If yes, # of weeks

    Are you nursing?

    Please select Yes or No

    YesNo Are you having pain or discomfort now? If so, what?
    YesNo Do your gums bleed when you brush?
    YesNo Have you had periodontal or gum treatment?
    YesNo Have you had any undesirable treatment experience? If so, what?
    YesNo Do you have any sores or lumps in your mouth that don’t heal?
    YesNo Are you unhappy with your smile? If so, why?
    YesNo Have you had orthodontic treatment?
    YesNo Are you currently under a physician’s care? If so, for what?
    YesNo Have you had any illness or surgery in the past year? If so, what?
    YesNo Are you changing dentists for any particular reason? If so, why?

    Conditions: Check all that apply

    Acid Reflux/GERD
    ADD/ADHD
    Allergies
    Anemia
    Angina Pectoris/ Chest Pain
    Arthritis
    Artificial Joints
    Artificial Heart Valve
    Asthma
    Blood Transfusion
    Cancer-Chemotherapy
    Chemical Dependency
    Congenital Heart Defect
    Congestive Heart Failure
    C-PAP machine/Sleep Apnea
    Dental Implants
    Diabetes
    Difficulty Breathing
    Eating Disorders
    Emphysema
    Epilepsy
    Fainting Spells
    Frequent Headaches
    Glaucoma
    Hay Fever
    Heart Attack
    Heart Murmur
    Heart Surgery
    Hemophilia or Clotting Disorder
    Hepatitis A, B and/or C
    Herpes/Cold Sores
    High Blood Pressure
    High Cholesterol
    HIV+ AIDS
    Joint Replacement
    Kidney Problems
    Liver Disease
    Low Blood Pressure
    Mitral Valve Prolapse
    Organ Transplant
    Pacemaker/Internal Defibrillator
    Mental Health Care
    Radiation Therapy
    Rheumatic Fever
    Seizures
    Sickle Cell Disease
    Sinus Problems
    Stroke
    Thyroid Problems
    Tuberculosis
    Ulcers

    Allergies

    Aspirin
    Codeine
    Dental Anesthetics
    Erythromycin
    Jewelry
    Latex
    Metals
    Penicillin
    Tetracycline
    Sulfa
    Other

    Other Information

    List any disease or condition not listed above

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