Date of Birth
Health History: Please choose the appropriate answer (leave blank if you do not understand the question).
1. Have you been under the care of or examined by a physician recently?
2. Has there been a change in your health within the last year?
3. Have you been hospitalized or had a serious illness in the last 3 years?
3-2: If yes, why?
4. Are you presently under the care of a physician?
5. Are you currently taking any medication or drugs?
5-2: Please list any medication or drugs you currently taking.
6. Do you have any allergies (penicillin, codeine, latex, hay fever, foods, metals?)
6-2: Please list any allergies.
7. Have you been warned against taking any specific type of medication?
7-2: Please list any medication you been warned against taking.
8. Do you take a daily low dose aspirin, Coumadin, warfarin, or any other blood thinner?
9. Do you take calcium replacement medications (oral bisphosphonates eg: Fosamax)?
10. Have you had any organ transplants?
11. Have you had a heart valve replacement?
12. Have you had a knee, hip or other joint replacement? Please SelectNeverWithin 6 MonthsWithin One YearWithin 2 Years
13. Has your Doctor recommended taking antibiotics prior to dental treatment?
14. Do you experience shortness of breath or chest pain?
15. Do you have a history or any heart problems? Please SelectNoHeart AttackAnginaBorn with a heart defect or abnormalityHeart MurmurMitral Valve Prolapse
16. Have you been prescribed nitroglycerin?
16-2: Do you carry nitroglycerin?
17. Have you had heart surgery? When and of what nature?
18. Do you have a pacemaker?
19. Have you been diagnosed with diabetes? Type I or Type II?
20. Have you had an injury, surgery or x-ray therapy to your face or jaws?
21. Has you energy level, weight, or appetite changed dramatically recently?
22. Do you bleed more than 10 minutes from a cut?
23. Do you bruise easily?
24. Do you have any restricted movement of your neck?
25. Do you have difficulty climbing stairs?
26. Do you currently or have you ever smoked?
27. Do you get dizzy spells or have you fainted?
29. Do you have any other disease, condition, or problem that you think the doctor should know about?
30. Are you pregnant? Suspect you are pregnant? Breast Feeding?
DENTAL HISTORY: Please check the appropriate answer (leave blank if you do not understand the question)
Last visit to the dentist?
Last professional teeth cleaning?
How frequently do you see your dentist?
How many times do you brush your teeth daily?
Are you presently having dental pain or discomfort? Where?
Are you aware of any dental problems? Where?
Are your teeth sensitive? If yes, to what?
Do your gums bleed? If so, when?
Are you aware of bad breath?
Do you have pain in your jaw joints or suffer from frequent headaches?
Do you grind or clench you teeth during the night?
Have you had problems with prior dental treatment?
Are you apprehensive before or during dental visits?
Are you interested in nitrous oxide (relaxing gas) for dental treatment?
Are you satisfied with the appearance of your teeth?
Does tooth whitening (bleaching) interest you?
Do you prefer composite (white fillings) over amalgam (silver fillings)?
Have you had orthodontic treatment?
Would you be interested in orthodontic treatment?
Do your wisdom teeth bother you?
Do you have missing teeth?
Are you interested in implant placement to replace missing teeth?
I certify that I have provided an accurate and complete personal medical/dental history. I understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary. *
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