Microsoft word - dental and medical information form


Date_______________ Patient’s Name __________________________________________
Have you ever had any serious trouble associated with previous dental treatment? If so, please describe _____________________________________________________________________ Does dental treatment make you nervous? ___ No ___ Slightly ___Moderately ___Extremely Correct answers to the following questions will allow your dentist to treat you on a more individual basis, providing the care appropriate for your particular needs. Your answers are for our records only and will be considered confidential. Yes No Yes No
Is it important for you to keep your teeth?
  Have you had injury to your head, neck or jaw? Are you dissatisfied with the appearance of your Is there anything about having dental treatment that Does food tend to get caught between your teeth?   Wore a bite plate or other appliance? Do your gums often bleed while brushing? Are you having dental pain at this time? Are you wearing removable dental appliances? Has anyone in your family ever had gum treatment? Have you noticed any loosening of teeth? Have you ever had periodontal treatment? If so,   Have you ever had excessive bleeding following when ____________________________________ an extraction, or do cuts take longer to heal? Do you clench your teeth while awake or asleep?   Do you get frequent blisters on your lips/mouth? Do you bite your lips or cheek frequently?   Do you get frequent swelling/lumps in mouth?   How often do you brush________________ Have you noticed pain (joint, ear, side of face)? Have you noticed difficulty in opening or closing? Have you noticed difficulty in chewing? Please explain if you answered “YES” to, or are uncertain about, any of the questions above: _______________________________________________________________________________ MEDICAL INFORMATION
Physician name______________________________ Date of last physical exam_____________ Physician address ________________________________________________________________ Has there been any change in you general health in the past year? ___Yes ___No Are you are under the care of a physician? If so, describe ________________________________ Have you had any serious illness within the past 5 yrs? If so, describe ______________________ Yes No Yes No Yes No
Do you have or have you
  Are you allergic to, or have
had any of the following
  you had any reactions to:
Cardiovascular Conditions?
  Are you or have you taken:
Do you have or have you had:
Other conditions?
  Women Only:
  Blood transfusion; Date ________   Are you on birth control pills
Are you required/did you take medication (as prescribed by American Heart Assoc.) prior to treatment: Y__ N__
Do you have a history of taking drugs for osteoporosis or cancer therapy? Y___N___ Commonly IV: pamidronate (Aredia), zoledronate (Zometa) (Reclast) ORAL: alendronate (Fosamax), Ibandronate (Boniva), Risedronate (Actonel) Do you regularly take supplements or herbal medicines? Y___N___ If yes do you regularly take any of the following? Vitamin E >400 units, Fish Oil >3g, Echinacea, Ephedra, Garlic, Ginkgo Biloba, Ginseng, Kava Kava, St. John’s Wort, Valerian Have you recently stopped taking any herbs? Y___N___
Have you substituted any herbs for prescription or over the counter drugs? Y___N___

Please describe any current medical treatment including all current drugs/medications, pending
surgery, recent injuries or any other information we should be aware of that we have not discussed:
To the best of my knowledge, the above information is complete and correct. I will not hold my dentist or any
other member of his/her staff responsible for any errors or omissions that I may have made in the completion of
this form.
I understand that a 1.5% Service Charge may be assessed on the unpaid balance of 60 days and over, and
also liable for legal and collection fees. I understand that I am responsible for payment in full upon completion of each
procedure. My insurance will be billed, if applicable, however, I am responsible for all charges not covered by my
_________________________________________________________ _________________
Signature of patient


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