Medical and dental history

Medical and Dental History
Patient Name_____________________________________ Date of Birth_______________

Please fill out the form completely to the best of your ability. Health problems that you may have, or medication(s) that you may be
taking may have an important interrelationship with the dental care you receive. Thank you.

Name of Primary care physician __________________________________________ Phone: (____)_____-___________
Address/Location of Primary care Physician:______________________________________________________________
List any prior Hospitalizations or surgeries including the year and reason for hospitalization or surgery:
Have you ever had a serious head or neck injury? If yes, explain:_______________________________________________________
Please list any medication(s) you are currently taking, including dosage and frequency:
Do you take, or have you taken Phen-Fen, Redux, Bonivia, Fosamax, Actonel, Didronel, Shelid, Aredia, Zometa? (please circle)
Are you on a special diet? If yes, explain:__________________________________________________________________________
Do you use tobacco? If yes, how much and how often?__________________________________ Smoke or smokeless (please circle)
Do you use controlled substances? If yes, please name and include the dosage and frequency:________________________________
Have you ever had prolonged or unusual bleeding? If yes, explain:______________________________________________________
Women Only: Are you □ Pregnant/Trying to get pregnant? □ Nursing? □ Taking Oral Contraceptives?
Are you allergic to any of the following? □ Aspirin □ Penicillin □ Codeine □ Acrylic □ Metal □ Latex □ Local Anesthetics
□ Other: ________________________________________ Please explain the reaction ______________________________________
Do you have, or have you had, any of the following?
□ AIDS/HIV positive
□ Artificial Heart Valve □ Drug Addiction □ Heart Trouble/Disease □ Pain in Jaw Joints □ Radiation Treatments □ Tuberculosis Have you ever had a serious illness not listed above? If yes, please explain: _________________________________________________
Have you ever had a reaction to local anesthetic? If yes, please explain: ___________________________________________________
Have you ever had complications or illness following dental treatment? If yes, please explain: ________________________________
Are you currently in any pain? If yes, please explain: _________________________________________________________________
When was your last dental checkup? ______________ Last dental cleaning? ________________ X-Rays? _________________________
What is the name of your previous Dentist? __________________________________Address/Location: __________________________
Have you ever been treated for Active Periodontal Disease? If yes, how long ago? ___________________________________________
How often do you brush? _________________ How often do you floss? ____________________
If you could change anything at all about your smile, what would it be? _____________________________________________________
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect
information can be dangerous to my (or the patient’s) health. It is my responsibility to inform the dental office of any changes in
medical status. If I ever have any change in my health condition or the medications I take, I will inform the Doctor on my next

Signature of Patient, Parent, or Guardian: ______________________________________________________ Date: _______________


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