Patient Medical History

 
 
1.Are you under medical treatment now?
 
2.Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
 
3.Are you taking any medication(s) including non-prescription medicine?
 
4.Have you ever taken Fen-Phen/Redux
 
5.Do you use tobacco?
 
6.Do you use controlled substance?
 
7.Are you wearing contact lenses?
 
8.Do you have or have you had any of the following?
 
High Blood Pressure
 
Heart Attack
 
Rheumatic Fever
 
Swollen Ankles
 
Fainting / Seizures
 
Asthma
 
Low Blood Pressure
 
Epilepsy / Convulsion
 
Leukemia
 
Diabetes
 
Kidney Diseases
 
AIDS or HIV Infection
 
Thyroid Problem
 
Heart Disease
 
Cardiac Pacemaker
 
Heart Murmur
 
Angina
 
Frequently Tired
 
Anemia
 
Emphysema
 
Cancer
 
Arthritis
 
Joint Replacement or Implant
 
Hepatitis / Jaundice
 
Sexually Transmitted Disease
 
Stomach Troubles / Ulcers
 
Chest Pains
 
Easily Winded
 
Stroke
 
Hay Fever / Allergies
 
Tuberculosis
 
Radiation Therapy
 
Glaucoma
 
Recent Weight Loss
 
Liver Disease
 
Heart Trouble
 
Respiratory Problems
 
Mitral Valve Prolapse
 
Other
 
9.Are you allergic to or have you had any reactions to the following?
 
Local Anesthetics (e.g. Novocain)
 
Penicillin or any other Antibiotics
 
Sulfa Drugs
 
Barbiturates
 
Sedatives
 
Lodine
 
Aspirin
 
Any Metals(e.g. nickel, mercury, etc)
 
Latex Rubber
 
Other(Please List)
 
10.Do you have a persistent cough or throat clearing not associated with a known illness(lasting more than 3 weeks)
 
11.Women Only
a) Are you pregnant or think you may be pregnant?
 
b) Are you Nursing?
 
b) Are you taking oral contraceptives?
 

Patient Dental History

 
 
1.Do your gums bleed while brushing or flossing?
 
2.Are your teeth sensitive to hot or cold liquids/foods?
 
3.Are your teeth sensitive to sweet or sour liquids/foods?
 
4.Do you feel pain to any of your teeth?
 
5.Do you have any sores or lumps in or near your mouth?
6.Have you had any head, neck or jaw injuries?
 
 
7.Have you ever experienced any of the following problem in your jaw?
 
Clicking
 
Pain(joint, ear, side of face)
 
Difficulty in opening or closing
 
Difficulty in chewing
 
8.Do you have frequent headachees?
 
9.Do you clench or grind your teeth?
 
10.Do you bite your lips or cheeks frequetly?
 
11.Do you ever had any difficult extractions in the past?
 
12.Do you ever had any prolonged bleeding following extractions?
 
13.Do you ever had any orthodontic treatment?
 
14.Do you wear dentures or partials?
 
15.Have you ever recieved oral hygiene instructions regarding the care of teeth and gums?
 
16.Do you like your smile?
 

Authorization and Release

 
I certify that I have read and understand the above infomation to the best of my knowledge. The above questions have been accuratly answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any infomation including the diagnosis and the records of any treatmet or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practioners. I authorize and request my insurance company to pay directly to the dentist od dental group insurance benefits otherwise payable to me to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.