Medical History FormAll information is confidential and will remain with this office. The dental administration staff is available to help you complete any portion of this form. Full completion of the forms will allow us to provide you with the highest standard of dental care. Thank you for your co-operation.Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 4Patient's Name *FirstMiddleLastPatient's gender *- Please select -MaleFemalePatient's Phone *If you need an appointment for someone under 18, please provide your own contact details.Patient's Email Address *If you need an appointment for someone under 18, please provide your own contact details.Patient's Current Address *Address Line 1CityState / Province / RegionNextAppointment DetailsWhom may we thank for referring you to our practice? *How did you hear about us? *Do you have a specific need? If yes, please describe: *How often do you see the dentist? *When was your last dental visit? And What was done? *When was the last time you had any dental x-ray taken? *How often do you brush? And How often do you Floss? *PreviousNextDo your gums ever bleed, are they swollen or painful? *YesNoDo you ever have jaw joint pain? *YesNoDo you ever clench or grind your teeth? *YesNoDo you ever bite your cheek or lip? *YesNoAre you aware of any swelling, sore spots or lump(s) in your mouth? *YesNoHave you ever had any traumatic injury to your face? *YesNoHave you ever noticed any loose teeth or have any of your teeth shifted? *YesNoDoes food catch between your teeth? *YesNoHave you been advised to take antibiotics before a dental appointment? *YesNoDo you smoke? If so, how much? *YesNoAre you wearing the transdermal nicotine patch? *YesNoDo you drink? If so, how much? *YesNoDo any of your teeth hurt/ache (e.g. sensitive to sweet, cold, hot, pressure)? *YesNoPlease describe:Have you had any kind of oral surgery?YesNoDoctor who performed oral surgery & His Phone nb :Have you ever had Orthodontics (Braces)?YesNoNextLayoutDoctor’s Name:Phone nb :Date / Time *DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920DateTimeDo you have or have had any of the following? Please Select One Heart problemssurgery diabetes strep throat pacemaker kidney problems tonsillitis chest pain hepatitisliver problems tuberculosis excessive bleeding rheumaticscarlet fever transmittable diseases faintingdizziness epilepsyseizures venereal disease, herpes blood disorders measlesmumpschicken pox HIVAIDS highlow blood pressure thyroid disease contagious diseasesanemia ulcersstomach problems anxiety problems sinus problems strokeparalysis psychiatric problems asthmaemphysema arthritisgout steroid therapy lungbreathing problems circulation problems cancertumors surgery in hospital artificial joints (e.g. hip, knee) radiation or chemotherapy organ transplantmedical implant pregnancyMonths ?Allergies:Please indicate any other medical conditions that we have not mentioned above:Please indicate any PRESCRIPTION or NON-PRESCRIPTION medications, pills or drugs which you are taking:Do you have FREQUENT, SEVERE headaches, earaches, ear/throat infections?Do you have any other questions or concerns?Any other family members patients at our office? List Them :LayoutDo you have Dental Insurance?YesNoEmployer of individual subscriberName of insurance Company:Certificate/ID#Employer of individual subscriber:Name of policy holder?Date of Birth of policy holderGroup/Policy #Is there Secondary/Co- insurance? If yes, Name of policy holder?Date of Birth of policy holderName of insurance Company:LayoutSingle Line TextGroup/Policy #Certificate/ID#(Signature) Patient ___ Parent___ Guardian___ Submit
