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A Full Spectrum
of Dental Services

Medical History


Are you likely to be available on short notice for future appointments

Person responsible for this Account

Do you have Dental Insurance

Medical History

1. Has there been any change in your general health in the past year?

2. Are you presently under the care of a physician?

3. Have you ever had a serious illness or have you ever been hospitalized?

4. Have you had a medical examination in the last year?

5. Are you presently taking any prescription or non-prescription medicines regularly?

6. Have you ever had or been treated for: (please check Yes or No)

Heart trouble, or stroke

Congenital heart disease, heart surgery, prosthetic cardiac valve, bacterial endocarditis, heart transplant

Abnormal blood pressure

Thyroid disease

Stomach or intestinal disorders, ulcer

Jaundice, Hepatitis A, B, C, liver disease, A.I.D.S.; are you H.I.V. positive?


Epilepsy or seizures

Gall bladder

Tuberculosis or any lung disease, bronchitis, emphysema, asthma

Arthritis or rheumatism

Growths or tumors, cancer

Blood disorders, anemia, malignant hyperthermia

Kidney disease

Mental or nervous disease

Drug or alcohol

Veneral disease

Injury to face or jaws

Joint replacements (hip, knee, etc.)

7. Do you ever have hay fever, hives or skin rash?

8. Are you allergic to ANYTHING?

9. Have you ever had a local anesthetic (freezing)?

10. Did it cause any problems?

11. Have you been warned against taking any medicine or lacal anesthetic (freezing)?

12. Have you ever fainted, had shortness of breath, chest pains or swollen ankles? (clicle)

13. Has your weight changed recently?

14. Are you on a special diet?

15. Do you bruise easily

16. Do you heal easily and normally?

17. Have you ever had cobalt, radiation or X-ray therapy (cancer treatment)?

18. Is there anything that the dentist should know regarding your medical history that has not been mentioned?

19. Have you been advised to take antibioties before dental treatment?

20. Women only: Are you pregnant?

21. Are you taking birth control pills?


2. How frequently do you see your dentist?

How would you describe the condition of your teeth and gums?

(Complete questions 4-20 only if you are having a complete dental examination)

4. Do your gums bleed easily?

5. Are your teeth sensitive to:

6. Do you feel you have bad breath at times?

7. Have you ever had jaw joint surgery?

8. Do you have pain in your jaw joints or suffer from migraine headaches?

9. Does any part of your mouth hurt when clenched?

10. Does your jaw crack or pop when opened widely? Which side?

11. Do you grind or clench your teeth during the day or night?

12. Have you ever been treated for TMJ symptoms? If yes,

13. Do you smoke or use chewing tobacco?

14. Have you ever experienced any sore spots or growths in your mouth? If so,

15. Have you noticed any loose teeth or have any of your teeth shifted?

16. Have you had any teeth extracted due to

17. Do you have any oral habits?

18. Have you ever had abscessed

19. Are you satisfied with the appearance of your teeth?

22. Are you nervous during dental treatment (circle) NOT AT ALL ← 1-2-3-4-5 → VERY ANXIOUS. If so, would you consider using additional techniques in addition to local anesthetic ("freezing")?

OFFICE POLICY: Your appointment time will be reserved especially for you. If you are unable to keep the appointment we will require 24 hours notice, otherwise it may be neccessary to charge for the time lost. Payment for dental services is due and expected on the date of service.



This is to certify that I, the undersigned, have given all the information above correctly to the best of my knowledge and consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable upon consultation with the dentist, including the use of general or local anesthetic, or nitrous oxide analgesia, as indicated. I also give my permission to have any photographs taken, to be used anonymously for lecturing or public education purposes. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary. Should there be ANY CHANGE IN MY HEALTH STATUS in future, I will advise this dental office before any treatment is rendered.
Also, I will personally assume responsibility for all fees associated with those procedures performed for myself and my dependents, on the date of service. I authorize the release of information in dental claims to be submitted electronically to my benefits plan administrator.