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					                                                              DENTAL HISTORY
Previous Dentist___________________________ Phone #_________________________________
Date of last dental visit_____________________ Date of last x-rays________________________
How often do you brush?______________________Floss?_________________________________
How do you feel about the appearance of your teeth?______________________________________
Please circle yes (Y) or no (N) if you have had problems with any of the following:

           Bad breath Y N          Bleeding gums Y N       Dry mouth Y     N      Sensitive teeth Y   N
           Clicking, popping or pain in jaw Y N     Clenching or grinding Y    N       Loose teeth Y    N
           Food collection between teeth Y N      Broken fillings Y N       Sores or growths in mouth Y                                  N

Have you ever been told you have gum disease or diagnosed with periodontal disease? Y N
Have you ever experienced an adverse reaction during or in conjunction with medical or dental treatment? Y N
Is there any other information about your dental health or previous treatment that you would like us to know?

                                                    MEDICAL HISTORY
Physician’s name______________________________________                  Phone#______________________________
Date of last visit_____________________ Have you had any serious illnesses or operations? Y            N
If yes, describe__________________________________________________________________________________
Are you currently under a physician’s care? Y N If yes, describe___________________________________
Have you ever taken Fen-Phen/Redux? Y             N
Have you ever had a blood transfusion? Y          N           If yes, approximate dates_______________________
Do you have a tobacco habit? Y          N smoking or chewing tobacco           If yes, how often________________
Are you interested in information regarding quitting? Y         N
Do you have or have you had any heart problems? Y N If yes, describe_________________________________________
Have you ever had to take an antibiotic pre-med prior to dental treatment? Y N If yes, reason_____________________
Please circle yes (Y) or no (N) if you have had any of the following:

Acid reflux               Y   N   Cough up blood               Y   N   Mitral valve prolapseY   N   Surgical implant        Y N
Aids/HIV positive         Y   N   Diabetes                     Y   N   Nervous problems Y       N   Swelling feet/ankles Y N
Anaphylaxis               Y   N   Epilepsy                     Y   N   Pace maker           Y   N   Thyroid disease         Y N
Anemia                    Y   N   Fainting                     Y   N   Psychiatric care     Y   N   Tonsillitis             Y N
Arthritis/rheumatism      Y   N   Glaucoma                     Y   N   Rapid weight loss    Y   N   Tuberculosis            Y N
Artificial heart valves   Y   N   Headaches                    Y   N   Radiation treatment Y    N   Ulcer/colitis           Y N
Artificial joints         Y   N   Heart monitor                Y   N   Respiratory disease Y    N   Veneral Disease         Y N
Asthma                    Y   N   Heart murmur                 Y   N   Rheumatic fever      Y   N   Allergies to latex               Y   N
Back problems             Y   N   Hemophilia/abnormal bleeding Y   N   Shingles             Y   N   Allergies to penicillin          Y   N
Blood disease             Y   N   Herpes                       Y   N   Shortness of breath Y    N   Allergies to other antibiotics   Y   N
Chemical dependency       Y   N   Hepatitis                    Y   N   Sinus problems       Y   N   Allergies to local anesthetics   Y   N
Chemotherapy              Y   N   High or low blood pressure   Y   N   Skin rash            Y   N   Material allergies:
Circulatory problems      Y   N   HPV                          Y   N   Sleep disorders      Y   N   (metal, chemicals, wool)         Y   N
Cortisone treatments      Y   N   Kidney disease               Y   N   Spina Bifida         Y   N
Cough, persistent         Y   N   Liver disease                Y   N   Stroke               Y   N
Is patient currently taking any medications? If yes, list all:           Does Patient have any other allergies? If yes, list all:
(include over the counter medicines and herbal supplements)                 ______________________________________
___________________________________________                                 ______________________________________
___________________________________________                                 ______________________________________
___________________________________________                                 ______________________________________
___________________________________________                                 Blood Pressure_________________________Date________
                                                                            (Dentist or dental clinician to document today)
Women only: Are you pregnant? Y                      N        Nursing ? Y    N       Taking birth control pills? Y N

I have reviewed the information on the questionnaire, and it is accurate to the best of my knowledge. I understand that this
information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in
my medical status, I will inform the dentist.
I authorize my dental insurance company to pay the dentist all insurance benefits otherwise payable to me for services
rendered. I authorize the use of this signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure payment of benefits. I understand that I am financially
responsible for all charges whether or not paid by insurance.

Signature__________________________________________                                       Date________________________

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