Medical History ADULT PATIENT or (Parent Guardian) REGISTRATION Are you the:(Required) PATIENT PARENT GUARDIAN Salutation(Required)Dr.Mr.Mrs.MsMissOtherLast Name(Required) First Name(Required) Initial Address(Required) Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth(Required) MM slash DD slash YYYY Age Sex Marital Status Home Phone(Required)Driver's Lic. No.(Required) Employer(Required) Phone(Required)Ext.Referring Dr. PhoneFamily Physician PhoneAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Medical Specialist Phone CHILD REGISTRATION or ADULT UNDER GUARDIANSHIP Last Name First Name Initial Prefers to be called Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth MM slash DD slash YYYY AgeSex PhoneSchool Grade Person Responsible for account: Self Spouse Other Method of payment: Cash Cheque Credit Card If other, please complete the following:Name Home PhoneAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer PhoneExt. Spouse's Name Occupation Employer PhoneExt. In case of emergency PhoneClosest family relative PhoneIs another family member or relative a patient at our office? PRIMARY DENTAL INSURANCE Name of Insured Date MM slash DD slash YYYY Employer Insurance Carrier Group/Policy Number Division I.D. Number or S.I.N. Certificate Number Dept. No. Coverage PercentageA B C D LimitsBasic Major Ortho DeductibleBasic Major Per Person Per Family Signature(s) Required Patient Insured Employer Submission Career Patient Employer Other SECONDARY DENTAL INSURANCE Yes No Name of Insured Date MM slash DD slash YYYY Employer Insurance Carrier Group/Policy Number Division I.D. Number or S.I.N. Certificate Number Dept. No. Coverage PercentageA B C D LimitsBasic Major Ortho DeductibleBasic Major Per Person Per Family Signature(s) Required Patient Insured Employer Submission Career Patient Employer Other MEDICAL HISTORY Date MM slash DD slash YYYY The information is required by the dentist to assist in proper diagnosis and treatment. ALL INFORMATION IS CONFIDENTIAL1. Have you ever had a serious illness requiring hospitalization or extensive medial care? Yes Don't Know/Maybe No Other 2. Are you presently under the care of a physician? Yes Don't Know/Maybe No If so, explain 3. Have you been hospitalized in the last 5 years? Yes Don't Know/Maybe No 4. Have you had a medical examination in the last year? Yes Don't Know/Maybe No 5. Do you use any prescription or non-prescription medicine including herbal remedies, regularly? Yes Don't Know/Maybe No Specify 6. Do you have any allergic condition: i.e. asthma, hay fever, skin rash, food allergies, metal or latex allergies? Yes Don't Know/Maybe No 7. Do any allergic reactions result in headache, shortness of breath, chest constriction, nausea? Yes Don't Know/Maybe No Specify: 8. Have you experienced any unusual reaction to any of the following? Local anaesthesia (freezing) Aspirin Penicillin Iodine Sulfonamide Barbiturates (sleeping pills) or any other medicine? If so, explain: 9. Have you been warned against taking any drug or medication? Yes Don't Know/Maybe No 10. Do you have or have you ever had any of the following? (please check) Heart murmur or mitral valve prolapse Stomach/intestinal problems Joint replacement (hip, knee, etc.) Mental or nervous disorder High/low blood pressure Hyper(hypo) glycemia Epilepsy or seizures Malignant hyperthermia Drug/alcohol addiction Venereal disease Any lung disease Thyroid disease Arthritis or rheumatism Scarlet of rheumatic fever AIDS Positive testing for HIV virus Jaundice Diabetes Tuberculosis Stroke Hepatitis A/B/C Herpes Heart attack Cold sores Cancer Kidney disease Sinus trouble Liver disease Cortisone/steroid therapy Other: 11. Have you ever had any known contact with AIDS virus? Yes Don't Know/Maybe No 12. Has any member of your family has diabetes? Yes Don't Know/Maybe No 13. Do you bruise easily or bleed abnormally? Yes Don't Know/Maybe No 14. Do your ankles swell during the day? Yes Don't Know/Maybe No 15. Have you have any weight changes recently? Yes Don't Know/Maybe No 16. Do you have any blood disorders such as anemia (thin blood), thalassemia (major, minor)? Yes Don't Know/Maybe No 17. Have you ever had radiation treatment or chemotherapy? Yes Don't Know/Maybe No If so, explain: 18. Have you ever had any injury, surgery or x-ray therapy to your face or jaws? Yes Don't Know/Maybe No 19. Do you have frequent severe headaches? Yes Don't Know/Maybe No 20. Do you have frequent earaches, ear/throat infections or any hearing difficulties? Yes Don't Know/Maybe No 21. Is your eyesight: Good Adequate Poor Do you wear contact lenses? Yes Don't Know/Maybe No 22. Are you on a special diet? Yes Don't Know/Maybe No 23.Have you ever fainted? Yes Don't Know/Maybe No 24. Do you ever experience shortness of breath or chest pain when walking or climbing stairs? Yes Don't Know/Maybe No Is so, explain: 25. Have you had any organ transplant or medical implants? Yes Don't Know/Maybe No 26. Do you have any disease, condition or problem that you think the doctor should know about? Yes Don't Know/Maybe No If so, explain: 27. Is there anything about yourself that we should be aware of? Yes Don't Know/Maybe No If so, explain: 28. WOMEN ONLYAre you pregnant? Yes Don't Know/Maybe No If so, which month are you in?123456789Are you taking any birth control pills? Yes Don't Know/Maybe No DENTAL HISTORY Date MM slash DD slash YYYY 1. Reason for today's visit: Exam Cleaning Emergency Other Is there a dental problem you would like to have taken care of as soon as possible? 2. How frequently do you see your dentist? 6 Months Yearly Other Former dentist Last dental visit Last cleaning Last full mouth series of x-rays X-rays requested 3. Have you been given oral hygiene instruction in Brushing Flossing Other By whom? 4. Brushing: Vigorous Light How often? Type of brush? 5. How often do you floss your teeth? 6. Other cleaning aids used: Floss Stimudents Toothpick Other 7.Are any of your teeth sensitive to: Cold Sweets Heat Other 8. Do your gums bleed when: Brushing Flossing Spontaneously 9. Is your sugar intake: High Medium Low 10. Have you ever had or do you now have any of the following? (please check) Bridges Partial dentures Full dentures Root canal fillings Dental implants Lost fillings Extractions Loose teeth Orthodontic treatment Bite adjustment Bite appliance/night guard Swelling or pain in your mouth or jaws Injuries to your face or jaws Surgery in your mouth Gum treatments Gag easily Difficulty opening or closing your jaw 11. Do you chew on only one side of your mouth? Yes Don't Know/Maybe No If so, why? 12. Does any part of your mouth hurt when clenched? Yes Don't Know/Maybe No 13. Does your jaw crack or pop when open widely? Yes Don't Know/Maybe No 14. Do you have any pain in your ears? Yes Don't Know/Maybe No 15. Have you experience any growth or sore spots in your mouth? Yes Don't Know/Maybe No If so, where? 16. Do you grind or clenched your teeth during the day or night? Yes Don't Know/Maybe No Do you - grind or clenched your teeth during the day or night? Yes Don't Know/Maybe No - mouth breath while awake or asleep? Yes Don't Know/Maybe No - bite your lips or cheek regularly? Yes Don't Know/Maybe No - hold any foreign objects with your teeth? (i.e. pipe, pencils, nails) Yes Don't Know/Maybe No - smoke Cigarettes Cigars Pipe Others No. per day 17. Check any of the following you are interested in or you have thought about: Orthodontics (braces) Bonding (straightening) Closing spaces between teeth Replacing missing teeth Repairing chipped teeth Bleaching (whitening teeth) Crowns (caps) Sports mouth guard Improved gum health Improving your bite Improving breath odor Improving your smile 18. Would you rate your current dental health as: Excellent Good Fair Poor 19. Do you have any emotional concern regarding your dental visit? Fear Pain Time Money Embarrassment Other concerns GENERAL RELEASE I, the undersigned, certify that I have provided an accurate and complete personal and medical - dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical - dental history. Should there be any change in either my health status or any other information I have provided, I will advise this dental office. I authorize the dentist to perform diagnostic procedures as may be required to determine necessary treatment. I understand that information provided from or to my medical doctor or another health care provider may be necessary. I have been advised of the privacy policy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that responsibility for payment of the dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services. Patient Parent Guardian Name Name of Guardian Draw SignatureUpload SignatureMax. file size: 50 MB.Reviewed by Treating Dentist: Date MM slash DD slash YYYY
