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Medical Histry Althugh dental persnnel primarily treat the area in and arund yur muth, yur muth is a part f yur entire bdy. Health prblems that yu may have, r medicatin that yu may be taking, culd have an imprtant interrelatinship with the dentistry yu will receive. Thank yu fr answering the fllwing questins. Are yu under a physician s care nw? Have yu ever been hspitalized r had a majr peratin? Have yu ever had serius head r neck injury? Are yu taking any medicatins, pills, r drugs? Please list belw. Yes r N Yes r N Yes r N Yes r N D yu take, r have yu taken, Phen-Fen r Redux? Yes r N Have yu ever taken Fsamax, Bniva, Actnel r any ther bisphsphnates? Yes r N Have yu ever been tld t pre-medicate with antibitics prir t a dental appintment? Yes r N D yu snre? Yes r N D yu have hypertensin? Yes r N Has anyne witnessed a sleep apnea/chking episde? Yes r N Is yur neck size fr male >17 female >15? Yes r N Have yu ever been tld yu have sleep apnea r d use a CPAP machine? Yes r N D yu use tbacc? Yes r N Wmen: Are yu? Pregnant/Trying t get Pregnant? Yes r N Taking Oral Cntraceptives? Yes r N Nursing? Yes r N Are yu allergic t any f the fllwing? Aspirin Penicillin Cdeine Lcal Anesthetics Acrylic Metal Latex Sulfa Drugs Other, if yes, please explain:

Medical Histry D yu have, r have yu ever had, any f the fllwing? Please circle yur answer. AIDS/HIV Psitive Drug Addictin Liver Disease Alzheimer s Disease Emphysema Lw Bld Pressure Anaphylaxis Epilepsy r Seizures Lung Disease Anemia Excessive Bleeding Mitral Valve Prlapse Angina Excessive Thirst Pain in Jaw Jint Arthritis/Gut Fainting Spells/Dizziness Parathyrid Disease Artificial Heart Valve Frequent Cugh Psychiatric Care Artificial Jint Frequent Headaches Radiatin Treatment Asthma Glaucma Recent Weight Lss Bld Disease Hay fever Rheumatic Fever Bld transfusin Heart Attack/Failure Rheumatism Breathing Prblem Heart Murmur Scarlet Fever Bruise Easily Heart Pacemaker Sickle Cell Disease Cancer Dementia Stent Placement Cataracts Heart Truble/Disease Sinus Truble Chemtherapy Hemphilia Strke Chest Pain Hepatitis A Swelling f Limbs Cld Sres/Fever Blisters Hepatitis B r C Thyrid Disease Cngenital Heart Disrder Herpes Tuberculsis Cnvulsins High Bld Pressure Ulcers Crtisne Medicine Hypglycemia Venereal Disease Diabetes Kidney Prblems Yellw Jaundice Have yu ever had any serius illness nt listed abve? Yes N Please Explain T the best f my knwledge, the questins n this frm have been accurately answered. I understand that prviding incrrect infrmatin can be dangerus t my (r patient s) health. It is my respnsibility t infrm the dental ffice f any changes in medical status. SIGNATURE OF PATIENT, PARENT, r GUARDIAN: DATE: Review by: Dctr Date B.P. Medical Updates: Date Dr. Medical Updates: Date Dr.

Dental Health Histry 1. Are yu having any discmfrt at this time? Yes N If yes, please explain: 2. Have yu ever had any serius truble assciated with previus dentistry? Yes N If yes, please explain: 3. Des dental treatment make yu nervus? N Slightly Mderately Extremely 4. Date f yur last dental visit? 5. Have yu ever been treated fr peridntal disease? Yes N 6. Hw ften d yu brush? Please circle f the texture if its: sft, medium, r hard.

7. D yu have r have yu ever had any f the fllwing? Please mark Bleeding gums Unpleasant taste/bad breathe Burning tngue/lips Frequent blister, lip/muth Swelling lump in muth Orthdntic Treatments (braces) Biting cheeks/lips Clicking/ppping jaw Difficulty pening r clsing jaw Lse teeth Sensitive t ht Sensitive t cld Sensitive t sweets Sensitive t biting Fd impactin Clenching/grinding Shifting in bite Change in bite 8. D yu use the fllwing? Electric tthbrush Dental Flss Fluride Rinse Tthpick 9. Check ne f the fllwing: My muth is Very cmfrtable Mderately cmfrtable Uncmfrtable 10. Check ne f the fllwing: I think the appearance f my muth is Excellent Satisfactry Dissatisfactry

11. Check ne f the fllwing: It is imprtant fr me t Keep my natural teeth Time Mney 12. Check ne f the fllwing: I dne what my dentist recmmend Always Usually Never 13. Check ne f the fllwing: Dental health is pririty High Lw 14. These are the things that are imprtant t me abut my dental health: Please explain:

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