Patient Medical History
Hospitalization for illness or injury
Any 'allergic'reaction to:
Aspirin, Ibuprofen, Acetaminophen, Codeine
Penicillin
Erythromycin
Tetracycline
Sulpha
Local Anesthetic
Fluoride
Metals (nickel, gold, silver)
Latex
Heart Problems or cardiac stent within the last 6 months
History of infective endocarditis
Artificial heart valve, repaired heart defect(PFO)
Pacemaker or implantable defibrillator
Artificial prosthesis (heart valve or joint - ie. hip, knee, shoulder)
Rheumatic or scarlet fever
High or low blood pressure
A stroke (taking blood thinners)
Anemia or other blood disorder
Prolonged bleeding due to a slight cut (INR>3.5)
Emphysema, sarcoidosis
Tuberculosis
Asthma
Breathing or sleep problems (ie.snoring, sinus)
Kidney disease
Liver disease
Jaundice
Thyroid, parathyroid disease, or calcium deficiency
Hormone deficiency
High cholesterol or taking statin drugs
Diabetes
Stomach or duodenal ulcer
Digestive disorders (i.e. gastric reflux)
Osteoporosis/Osteopenia (i.e. taking bisphosphonates)
Arthritis
Glaucoma
Contact Lens
head or neck injuries
Epilepsy, convulsions (seizures)
Neurologic problems (attention deficit disorder)
Viral infections and cold sores
Any lumps or swelling in the mouth
Hives, skin rash, hay fever
Venereal disease
Hepatitis
HIV / AIDS
Tumor, abnormal growth
Radiation therapy
Chemotherapy
Emotional problems
Psychiatric treatment
Antidepressant medication
Alcohol / drug dependency
Are you:
Presently being treated for any other illness(es)
Aware of a change in your general health
Taking medication for weight management(i.e. fen-phen)
Taking dietary suppliments
Often exhausted of fatigued
Subject to frequent headaches
A smoker or smoked previously
FEMALE - taking birth control pills
FEMALE - pregnant
MALE - prostate disorder

Please advise us in the future of any change in your medical history or any medications you may be taking.

List current medications, supplements, and or vitamins.

Drug
Purpose
Drug
Purpose

Ask for an additional sheet if you are taking more than 12 medications

We reserve the right to charge for appointments cancelled or broken without 24 hours advance notice

Please refer to our 24 hour answering service for after hours communications.

Dental History
I routinely see my dentist every:

Please answer YES or NO the following:

PERSONAL DENTAL HISTORY

Have you ever had complications from past dental treatment?
Have you ever had trouble getting numb or had any reactions to local anesthetic?
Did you ever have braces, orthodontic treatment or had your bite adjusted?
Have you ever had any teeth removed?

SMILE CHARACTERISTICS

Is there anything about the appearance of your teeth that you would like to change?
Have you ever whitened (bleached) your teeth?
Have you felt uncomfortable or self conscious about the appearance of your teeth?
Have you been disappointed with the appearance of previous dental work?

BITE AND JAW JOINT

Do you have any problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
Do you/would you have any problems chewing gum?
Do you/would you have any problems chewing bagels, baguettes, protein bars, or other hard foods?
Are your teeth crowding or developing spaces?
Do you chew ice or have any other oral habits?
Do you clench your teeth in the daytime or make them sore?
Do you have any problems with sleep or wake up with an awareness of your teeth?
Do you currently wear a nightguard?

GUM AND BONE

Do your gums bleed when brushing or flossing?
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
Have you ever noticed an unpleasant taste or ordor in your mouth?
Is there anyone with a history of periodontal disease in your family?
Have you ever experienced gum recession?
Have you ever had any teeth become loose on their own (without injury) or do you have difficulty eating apples?
Have you experienced a burning sensation in your mouth?