health history

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Patient Information

First name

Last name

Date of Birth

Sex: *

Male

Female

Dental/Medical History

Now or in the past, has the patient had:

Bone fractures or major injuries to the face, head, or neck? *

Yes

No

Cancer, tumor, radiation treatment or chemotheraphy? *

Yes

No

Endocrine or thyroid problems? *

Yes

No

Diabetes or low blood sugar? *

Yes

No

Kidney or liver problems? *

Yes

No

Stomach ulcer, hyperacidity or acid reflux? *

Yes

No

Arthritis, joint problems or osteoporosis? *

Yes

No

AIDS, HIV positive or any STDS? *

Yes

No

Seizures or fainting spells? *

Yes

No

Erupting teeth very early or very late? *

Yes

No

Eating disorder? *

Yes

No

Frequent headaches or migraines? *

Yes

No

Excessive bleeding, bruising or anemia? *

Yes

No

Heart defects, heart murmur or rheumatic heart disease? *

Yes

No

Vision, hearing, or speech problems? *

Yes

No

Frequent ear infections, colds or throat infections? *

Yes

No

Asthma, sinus problems or hayfever? *

Yes

No

Tonsil or adenoid condition? *

Yes

No

Supernumerary (extra) or congenitally missing teeth? *

Yes

No

Chipped or injured primary or permanent teeth? *

Yes

No

Any sensitive or sore teeth? *

Yes

No

Any lost or broken fillings? *

Yes

No

Jaw fractures, cysts or infections? *

Yes

No

Any teeth treated with root canals or pulpotomies? *

Yes

No

Frequent canker sore or cold sores? *

Yes

No

Mouth breathing habit or snoring at night? *

Yes

No

Frequent oral habits (sucking finger, chewing pen etc.) *

Yes

No

Teeth causing irritation to lip, cheek or gum? *

Yes

No

Tooth grinding or clenching? *

Yes

No

Clicking or locking jaw joints? *

Yes

No

Soreness in jaw muscles or face muscles? *

Yes

No

Ringing in ears, difficulty in chewing or opening jaw? *

Yes

No

Been treated for TMJ or TMD problems? *

Yes

No

Been diagnosed with gum disease or pyorrhea? *

Yes

No

Frequently breathe through mouth? *

Yes

No

Chew, smoke tobacco, or have a history of substance abuse? *

Yes

No

Taken any medications for bone disorder? *

Yes

No

Does the patient have allergies or reactions to any of the following?

Local anesthetics (novocaine, lidiocaine, xylocaine) *

Yes

No

Latex (gloves, balloons) *

Yes

No

Aspirin or Ibuprofen *

Yes

No

Penicillin/Amoxicillin *

Yes

No

Other Allergies:

List any medications or nutritional supplements taken and for what:

Are there any behavioral, mental, medical or physical disabilities we need to be aware of?

Does the patient require an antibiotic pre-medication before dental procedures? *

Yes

No

How old was the patient when they began their 1st menstrual cycle?

Is the patient pregnant or currently trying to become pregnant? *

Yes

No

I have answered the above questions accurately and to the best of my knowledge.

Your Signature

Today's Date:

Thanks for submitting!

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