Medical History


Primary reason for this dental appointment: Examination   Emergency   Consultation

Dental History

Do you have a specific dental problem? Yes   No  
Do you have dental examinations on a regular basis? Yes   No  
Do you think you have active decay or gum disease? Yes   No
Do you brush and floss on a routine basis? Yes   No  
Do your gums ever bleed? Yes   No  
Do you like your smile? Yes   No  
Does food catch between your teeth? Yes   No
Any loose teeth? Yes   No
Do you want to keep your remaining teeth? Yes   No
Do you ever have clicking, popping or discomfort in the jaw joint? Yes   No
Do you brux or grind? Yes   No
Have your past experiences in a dental office always been positive? Yes   No
Do you smoke or chew? Yes   No
Any sores or growths in your mouth? Yes   No  


Medical History

Are you under a physician’s care now? Yes   No
Have you ever been hospitalized or had a major operation? Yes   No  
Have you ever had a serious injury to your head or neck? Yes   No  
Are you taking any medications, aspirin, vitamins, herbals, pills or drugs? Yes   No  
Are you on a special diet? Yes   No  

Are you allergic to any medications or substances? Please check all that apply.
               

Women, please check any of the following that apply to you.
Pregnant/trying to get pregnant Nursing Taking oral contraceptives

Do you now have or have ever had any of the following medical conditions? Do you take any of these medicines? Please check any that apply.
*If yes, please call prior to your appointment. Premedication or changes in medication may be required.



























































































Have you ever had any other serious illness not checked above? Yes   No  
Do you wish to talk to the dentist privately about any problems? Yes   No
To the best of my knowledge, all the preceding answers are correct. If I have any changes in my health status or if my medicines change, I shall inform the dentist and staff at the next appointment without fail.

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