Patient name

Patient Name ________________________________ Date of Birth: _________________________ PATIENT MEDICAL HISTORY
Physician’s Name:_______________________________________ Address:_____________________________________________ Physician Phone #:___________________________ Date of your last Physical Exam:__________ Are you now under the care of a Physician Do you require medication/antibiotics before dental treatment? No If Yes, please explain__________________________________ Are you taking any medication (Include non-prescription medicine)? If yes, what medicine(s) are you taking?_____________________________________________________________________________________
ARE ALLERGIC TO OR HAVE YOU HAD REACTIONS TO:
Barbiturates, sedatives or sleeping pills Local or topical anesthetics (i.e. Novocain) HAVE YOU EVER TAKEN OR ARE YOU TAKING, ANY OF THE FOLLOWING BONE SAVING MEDICATIONS:
Have there been any changes in your General Health Do you or have you used controlled substances? Have you ever been hospitalized for any surgical Do you have any disease, condition or problem not listed below that you think I should know about? Please Explain __________________________ Have you ever been treated for osteoporosis? Are you being treated with medication for any other
Women Only:
Are you pregnant or think you may be pregnant
DO YOU HAVE OR HAVE YOU EVER HAD THE FOLLOWING:

Other _______________________________________________ G:\ADULT 2009\Forms\Patient Medical History Hardcopy.doc PATIENT DENTAL HISTORY
When your last dental visit? ________________ What was done then? _________________________ How often do you usually visit the dentist? _________________________________________________ Previous Dentist (Name and Location)_____________________________________________________ Have you had a complete series of dental films (x-rays) taken? When?____________Where?___________________ How often do you brush your teeth? How often do you floss your teeth? Day/week/not often/ never Do Is your drinking water fluoridated? Yes Do your gums bleed while brushing or flossing? Have you noticed any loosening of your teeth? Are your teeth sensitive to hot or cold liquids/foods? Are your teeth sensitive to sweet or sour liquids/foods? Have you ever had periodontal treatment (GUMS) ? Do you have any sores or lumps in or near your mouth? Ever worn a bite plate or other appliance? Have you had any head, neck or jaw injuries? Have you ever had difficult extractions in the past? Have you ever experienced any of the following problems in your Have you ever had any prolonged bleeding Do you wear dentures, partials, retainers/splints? If yes, date of placement_______________ Have you ever received oral hygiene instructions Do you bite your lips, cheeks or fingernails? regarding the care of your teeth and gums? If you could change anything about your smile, what would you change?_________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Authorization and release I certify that I have read and understand the above information to best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. X__________________________________________________ Date_______________________________________ Signature of patient or parent/guardian if minor G:\ADULT 2009\Forms\Patient Medical History Hardcopy.doc

Source: http://www.fmartindds.com/docs/patient_medical_history.pdf