Patient name________________________________________________________________date_______________________

PATIENT NAME________________________________________________________________DATE_______________________ MEDICAL/DENTAL HISTORY
Previous dentist and date of last dental exam/x-rays/cleaning:
Do you take or have you ever taken medications for osteoporosis, ___________________________________________ including Actonel, Boniva, Didronel, Fosamax, Skelid, (risedronate, Do you like the appearance of your teeth? ibandronate, etidronate, alendronate, tiludronate)? Are you having pain or discomfort at this time? Have you ever received I.V. Aredia, Bonefos, Zometa (pamidronate, Are your teeth sensitive to hot or cold or sweets? Do your gums bleed while brushing or flossing? Have you ever had radiation to head and neck? Have you experienced any of the following problems History of prolonged bleeding following Extractions? in your jaw? Clicking? Pain (joint, ear, side of face), Difficulty in chewing, opening or closing? Are you allergic to or have you had any reactions to the following? Have you ever been hospitalized for any surgical operation or serious Local Anesthetics, Penicillin or any other Antibiotics, Clindamycin, illness within the last 5 years? If yes, please explain Codeine, Tylenol, Barbiturates, Any Metals (e.g. nickel, copper.), Latex, Other (please list) _________________________ Have you ever taken Phen-Fen or similar diet drugs? including non-prescription medicine? If yes, list below: Are you pregnant or think you may be pregnant? Is there anything about being here for treatment that bothers you? Have you had a previous negative experience in an office/clinic before? Have you previously required special procedures or medication for Do you Snore? Or have sleep apnea? Yes/No Physician _________________________________Office phone _______________________________Date of last exam ________Do you or have you had any of the following?Allergies (to medicines) Authorization and Release
1. I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I
understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the
diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payers
and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise
payable to me. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
2. The undersigned hereby authorizes doctor to order x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by doctor
to make a thorough diagnosis of the patient’s deemed needs and to administer medications necessary for my dental care.
3. I also authorize doctor to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy
indicated for such treatment. I understand that using anesthetic agents embodies a certain risk. Furthermore, I authorize and consent that doctor
choose and employ such assistance as deemed fit to provide recommended treatment.
4. I understand that all responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at
the time services are rendered unless other arrangements have been made. I understand that my dental insurance carrier may pay less than the actual
bill for services. In the event payments are not received by the agreed upon dates, I understand that a 1 ½ % finance charge (21% APR) may be added
to my account, in addition to any collection charges and/or attorney fees.
5. I understand that where appropriate, credit bureau reports may be obtained.
6. I understand that it is my responsibility to advise your office of any changes in the information contained in this form
X_____________________________ Reviewed by Dr.____________________Signature of patient (or parent if minor)

Source: http://smilela.com/sites/default/files/public/resources/330/2_Medical%20History.pdf