Please enable JavaScript in your browser to complete this form.HEALTH HISTORYNameDatePhoneAre you under the care of a Physician?YesNoWhy?What medications or pills are you currently taking?What Herbs or diet supplements do you take regularly?Are you taking medication for preventing osteoporosis? (Please list)Are you allergic to any medications or substances?AspirinCodeinePenicillinLatexSulfaJewelry/MetalsOtherHave you ever been instructed to pre-medicate with antibiotics before receiving dental care?YesNoFor Women: Are you pregnant?YesNoPlease check any of the following that you have experienced?Rheumatic FeverHeart MurmurMitral Valva ProlapseAny Heart ProblemHeart SurgeryPacemakerJoint ReplacementHigh Blood PressureDiabetesFainting/DizzinessSinus ProblemsDo You Smoke?Do You Chew Tobacco?Cancer/TumorsRadiation TxChemotherapyAsthmaEpilepsy/SeizuresKidney DiseaseAIDS/HIVHemophiliaHepatitisLiver DiseaseVenereal DiseaseAlcohol AddictionDrug AddictionPlease list any medical condition not listed above.DENTAL HISTORYReason for today’s visit?When was your last dental check-up?How often do you brush your teeth?Last panoramic or full set of x-rays taken?How often do you floss your teeth?Please check any dental problems that applyToothacheBroken or chipped teethBleeding gumsHot, cold, sweet sensitivityDifficulty chewingLoose teethSores in the mouthSwelling or lumpsJaw joint pain (TMJ)SnoringBad BreathDenture problemsDifficult to numbExcessive bleeding after extraction or surgery?Are there any other concerns?If you could improve your smile, what might you change?Whiten teethRepair chipped teethStraighten uneven teethReplace old fillings or crownsClose spacesReplace missing teethAre there any other concerns?Authorization *By submitting this form you understand that the information you have given is correct. You authorize release of this information for medical consultation and referral, as well as insurance submission. You also understand that it is your responsibility to inform this office of any changes of your medical status.Submit
