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Patient Health History


In case of Emergency (Person’s Name/Number): ________________________________________________________________________________________________________________________

Date of last Medical Exam: __________________________How would you describe your health? ______________________________________________________________________________

Do you have a Medical Physician: ___________________Name of Physician: _________________________________________________________________________________________________


1.        Are you now or have you been under the care of a physician within the past five years: ________If so, why: ________________________________________________________

2.        Have you had any major surgery/hospitalization: ______________________________________________________________________________________________________________

3.        Are you now or have you recently been taking any medication? __________If yes, name of meds and for what _______________________________________________________ _____________________________________________________________________________________________________________________________________________________________

4.       Have you taken Phen-fen/Redux before? ______________When? ________________Have you seen your physician after that? __________________________________________

5.        Are you allergic to or have any reactions to any of the following: (mark each applicable box)

                                                                                                  Y   N                            Y   N                                         Y    N                                                                                                   

Local Anesthetics (e.g. Lidocaine)









Penicillin or any antibiotics






Latex Rubber



Sulfa Drugs






Others (please list)



Any metals (e.g., nickel, mercury










         6.    Women Only:

                                                                                                                               Y   N

Are you pregnant or think you may be pregnant?



Are you nursing?



Are you practicing birth control medication?




7.        Do you or have you had any of the following: (please mark each applicable box)

                                                      Y  N                                                    Y   N                                              Y   N                                           Y   N

Heart Attack



Joint Replacement/Implant






Cold Sores



Heart Failure



Kidney Trouble






Genital Herpes



Heart Surgery






Pain in Jaw Joints



Fainting/Dizzy Spells



Heart Disease






AIDS/HIV infection






Angina Pectoris






Liver Disease



Psychiatric Treatment



Heart Murmur






Hepatitis A (infectious)



Sickle Cell Disease



High Blood Pressure






Hepatitis B (serum)



Bleeding Gums



Rheumatic Fever



Hay Fever/Allergies



Hepatitis C



Tooth Pain



Congenital Heart Defect



Sinus Trouble



Yellow Jaundice



Bad Breath



Scarlet Fever






Blood Transfusion



Chronic Headaches



Artificial Heart Valve



Thyroid Disease



Drug Addiction



Chronic Neckaches



Mitral Valve Prolapse



Radiation Therapy






Cosmetic Surgery



Heart Pace Maker









Cortisone Medicine












Others (please list)



High Cholesterol



Tobacco/nicotine use










Patient Dental History

Name of Previous Dentist and Location _________________________________________________________________Date of Last Exam: ______________________________________

                                                                                                             Y   N                                                                                                                                            Y      N

Do your gums bleed while brushing or flossing?



Do you have frequent headaches?



Are your teeth sensitive to hot or cold liquids/foods?



Do you clench or grind your teeth?



Are your teeth sensitive to sweet or sour liquids/foods?



Do you bite your lips or cheeks frequently?



Do you feel pain in any of your teeth?



Have you ever had any difficulty with extractions?



Do you have any sores or lumps in or near your mouth?



Have you ever had any prolonged bleeding after extractions?



Have you had any head, neck, or jaw injuries?



Have you had any orthodontic treatment?



Have you ever experienced any of the following in your jaw?



Do you wear dentures or partials? If yes, date of placement? ____________________     



                   a) Clicking



Have you ever received oral hygiene instructions (teeth and gums)?



                   b) Pain (joint, ear, side of face)



Do you like your smile?



                   c) Difficulty in opening or closing






                   d) Difficulty in chewing







Authorization and Release:  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 payors and /or health practitioners.



Signature of Patient/Parent or Guardian: _______________________________________________________________________Date: ______________________________________________


Doctor’s Signature: ______________________________________________________________________________________________Date: ______________________________________________


Doctor’s Comments: _________________________________________________________________________________________________________________________________________________