Patient Medical History

General Information

Your Name (required)

Your Email (required)

Preferred name

Reason for visit

Date of last dental visit/

Date of last dental x-rays

Physician Information

Physician or Clinic Name

Physician/Clinic Phone or Location

Pharmacy

Pharmacy Phone

Other Information

How often do you brush?

How often do you floss?

Do you smoke or use tobacco products?

Please list any medication you are now taking

*It is especially important to know if you are taking bone/osteoporosis medications (Fosamax,Boniva, Prolia, Reclast, or Actonel) tranquilizers, phenobarbital or dilantin, blood thinners (aspirin, Warfarin/Coumadin, Plavix, Xarelto, Eliquis), steroid medicines, nitroglycerin, arthritis or thyroid medicine.

MaleFemale

If Female

Are you taking Birth Control Pills?

Are you pregnant? If yes, # of weeks

Are you nursing?

Please select Yes or No

YesNo Are you having pain or discomfort now? If so, what?
YesNo Do your gums bleed when you brush?
YesNo Have you had periodontal or gum treatment?
YesNo Have you had any undesirable treatment experience? If so, what?
YesNo Do you have any sores or lumps in your mouth that don’t heal?
YesNo Are you unhappy with your smile? If so, why?
YesNo Have you had orthodontic treatment?
YesNo Are you currently under a physician’s care? If so, for what?
YesNo Have you had any illness or surgery in the past year? If so, what?
YesNo Are you changing dentists for any particular reason? If so, why?

Conditions: Check all that apply

Acid Reflux/GERD
ADD/ADHD
Allergies
Anemia
Angina Pectoris/ Chest Pain
Arthritis
Artificial Joints
Artificial Heart Valve
Asthma
Blood Transfusion
Cancer-Chemotherapy
Chemical Dependency
Congenital Heart Defect
Congestive Heart Failure
C-PAP machine/Sleep Apnea
Dental Implants
Diabetes
Difficulty Breathing
Eating Disorders
Emphysema
Epilepsy
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Heart Attack
Heart Murmur
Heart Surgery
Hemophilia or Clotting Disorder
Hepatitis A, B and/or C
Herpes/Cold Sores
High Blood Pressure
High Cholesterol
HIV+ AIDS
Joint Replacement
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Organ Transplant
Pacemaker/Internal Defibrillator
Mental Health Care
Radiation Therapy
Rheumatic Fever
Seizures
Sickle Cell Disease
Sinus Problems
Stroke
Thyroid Problems
Tuberculosis
Ulcers

Allergies

Aspirin
Codeine
Dental Anesthetics
Erythromycin
Jewelry
Latex
Metals
Penicillin
Tetracycline
Sulfa
Other

Other Information

List any disease or condition not listed above

Signature: Please Sign Below

(After you click Submit, please make sure you complete Registration and X-ray request forms)

Δ