ARE YOU ALLERGIC to ANY of the FOLLOWING? Aspirin/Ibuprofen/Acetaminophen Codeine

Dental History

Purpose of visit:
Date of last examination: Date of last teeth cleaning: Date of last full mouth x-rays:
How often do you brush? How often do you floss?
Have you ever had a dental anesthetic? If yes, have you ever had a bad reaction to a local anesthetic?
Have you ever had any complications during or after dental treatment? Do you gag easily?
Have you ever had periodontal (gum) treatment? If yes, date:
Are any of your teeth sensitive to the following (please circle): sweets hot cold
Do you have trouble chewing? If yes, please explain:
Do you have any jaw pain/numbness when you chew? Do you clench or grind your teeth?
Do you suffer from dry mouth or lack of saliva? Do you smoke? Do you use “smokeless” tobacco?
Have you ever had orthodontic treatment? If yes, by whom and how long ago?
Do you wear dentures or a partial denture? If yes, when were they made?
Is there anything else that I should know about that was not listed above?

Medical History

ARE YOU ALLERGIC TO ANY OF THE FOLLOWING?[ ] Aspirin/Ibuprofen/Acetaminophen[ ] Codeine

[ ] Penicillin/Amoxicillin[ ] Erythromycin[ ] Latex[ ] Local Anesthetic[ ] Fluoride

[ ] Sulfa[ ] Other: Please explain: [ ] No Allergies

ARE YOU TAKING ANY MEDICATIONS? If yes, please list the name of the medications and treatment the medication is used for:

DO YOU OR HAVE YOU EVER HAD:YesNoYesNo

Heart problems or cardiac stent within last 6 months[ ][ ]High cholesterol[ ][ ]

Artificial heart valve, pacemaker (circle)[ ][ ]Diabetes(type:) (Onset:)[ ][ ]

Heart surgery (type:)[ ][ ]Stomach ulcers[ ][ ]

Heart murmur, attack[ ][ ]Osteoporosis/osteopenia[ ][ ]

Heart Disease[ ][ ]Arthritis/rheumatoid arthritis[ ][ ]

Shortness of breath[ ][ ]Artificial Joints/Pins/Screws[ ][ ]
Stroke [ ][ ]Joint pain/swelling [ ][ ]
Chest pain, pressure[ ][ ]Fainting or dizzy spells[ ][ ]
Anemia or other blood disorder[ ][ ]Epilepsy, convulsions, or seizures[ ][ ]

Taking blood thinners[ ][ ]Neurological disorder, explain[ ][ ]

Prolonged bleeding or easily bruised[ ][ ]Taking antidepressant medication[ ][ ]

Blood transfusion[ ][ ]Hepatitis (Type:)[ ][ ]

High or low blood pressure(circle one)[ ][ ]HIV/AIDS[ ][ ]

Rheumatic or Scarlet Fever[ ][ ]Venereal disease[ ][ ]

Chronic cough, blood in sputum[ ][ ]Cold sores/fever blisters[ ][ ]

Emphysema/Bronchitis (circle one)[ ][ ]Tumor or abnormal growth[ ][ ]

Tuberculosis[ ][ ]Cancer(Type:)[ ][ ]

Asthma[ ][ ]Radiation therapy[ ][ ]

Breathing/sleep problems(i.e. snoring, sleep apnea)[ ][ ]Chemotherapy[ ][ ]

Sinus trouble/Sinusitis[ ][ ]Alcohol/drug dependency,explain[ ][ ]

Frequent nosebleeds [ ][ ]Digestive disorders, explain:[ ][ ]
COPD[ ][ ]Overactive bladder, frequent UTI[ ][ ]
Frequent sore throat, hoarseness[ ][ ]Autoimmune disease[ ][ ]
Kidney Disease [ ][ ]ARE YOU:

Liver disease[ ][ ]Being treated for any other illness[ ][ ]

Jaundice[ ][ ]Subject to frequent headaches[ ][ ]

Gout[ ][ ]FEMALE – taking birth control pills[ ][ ]

Thyroid problems(circle one: hyper- or hypo-)[ ][ ]FEMALE – currently pregnant[ ][ ]
Hormone deficiency[ ][ ]MALE – with prostate disorders[ ][ ]
Smoke(i.e. cigarettes, cigars)[ ][ ]
Use “smokeless” tobacco/chew[ ][ ]

I hereby grant authority to the dentist in charge of the patient whose name appears on this health history form, to administer any treatment, or to administer anesthetics, analgesics, sedatives, and/or nitrous oxide sedation, and to perform such operations as may be deemed necessary or advisable in the diagnosis and treatment of the patient.

Signature: Date:

Medical UpdateSignature: Date: Signature: Date:
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