Patient Informatio
on Forms
First Namee ___________
_________ Lasst Name ___________________________
DOB __________ Date __
__________
DENTAL HISTORY
Have you been
b
having sp
pecific problem
ms?
Yes No
N Describe: ____________
_
______________________________
Last dentall visit? ______
________ Purppose: _______________________________________________________________
Has fear orr discomfort keept you from reegular visits? Yes
No
Good Faair
How wouldd you describee your present dental
d
health?
Poor
Do you thiink you have acctive dental dissease: Decay:
Yes
Noo Gum Diseasee: Yes
N
No
Home caree: Brush?
Yes
Y
No Flosss?
Yes
No
Do your guums ever bleed
d?
Yes
N How often?? ____________
No
Are you trooubled with baad breath?
Y
Yes
No
Do you likke your smile?
Yes
No Please describbe: __________
___________________________________________
Any historry of smoking or
o chewing tobbacco? If yes, please
p
describee: _________________________________________
Would youu be interested in quitting? Yes No
Are you innterested in any
y cosmetic impprovements in your
y
smile or want
w to learn more
m
about bondding, veneers and
a
implants, replacing
r
old fiillings, or bleacching?
Yess
No Descriibe: _______________________________________
Have you ever
e
had any unusual
u
effects from previous dental treatmeent?
Yes No Describe:: ________________
_____________________
________________________________________________________________________________
MEDICAL
L HISTORY
Medical Doctor’s name: ___________________________ Last Physiccal Exam: ___________ Phonee #: ______________
(Women) Are
A you pregnaant?
Yes No How longg? ____________________________________________________
Are you unnder a doctor’ss care now?
Yes No If so,
s for what reaason? _____________________________________
Are you taking any medications, pills, drugs?
d
Yess
No Pleasee list ______________________________________
_____________________
________________________________________________________________________________
Have you ever
e
had any of the followingg?
Yes
Yes
Yes
Yes
Yes
Yes
No Arthritiss
No Asthma
No Cancer
No Diabetes
No Epilepsy
No Glaucom
ma
Yess
Yess
Yess
Yess
Yess
Yess
No Hepatiitis
No Herpes
No H.I.V or A.I.D.S
No High blood
b
pressure
No HPV
No Jaundiice
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No Stroke
N
N Prolonged Bleeding
No
B
N Prosthetic Jooint
No
N Psychiatric Care
No
N Tuberculosiis
No
N Migraine
No
N Heart Troubble
No
Have you ever
e
had any other serious illness? Yes No Explainn: _________________________________________
Have you been
b
hospitalizzed in the last two
t years?
Yes
No Why?
W
______________________________________
Drug Allerrgies:
Yes
None Pleaase list: _____________________________________________________________
Do you wish to talk to the doctor about any problem not
n listed?
Y
Yes
No
Commentss: ___________
_______________________________________________________________________________
Signature: ____________
_______________________________________________________________________________
Office Usee: Blood Pressu
ure: _________________________ Dr’s Signature: _____________________________________