MEDICAL HISTORY

    Patient Name

    Birth Date

    DENTAL HISTORY
    What is your reason for today’s visit?

    When was your last visit to a dentist?

    Have your past dental experiences been satisfactory?

    How do you feel about the appearance of your teeth?

    MEDICAL HISTORYDo you have or have you had any of the following? (Please check all that apply to you)

    Artificial Joints

    Diabetes/Type

    Cancer (Yr)

    Osteoporosis (Yr Diagnosis)

    If yes to any of the above please explain

    Physician

    Tel#

    Date of last physical exam

    Please list all medications as well as any over the counter medication, vitamins or Herbal or Homeopathic remedies

    Are you currently under a physician’s care?

    Explain

    Do you take aspirin daily?

    Do you Require Antibiotic Pre-Medication?

    Allergies/Reactions to Medications, or other allergies? (Latex or food?)

    (Women) Are you Pregnant?

    Nursing?

    Taking Birth Control?

    Do you suffer from Dental Anxiety? If so please rate your anxiety from 1-10


    To the best of my knowledge, the questions on this form have been accurately answered. I understand providing incorrect Information can be dangerous to my health. It is my responsibility to inform the dental office of any changes to my health.

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