Health and Dental History Form

Health and Dental History

Are you in good health?

Have you ever had excessive bleeding following an extraction?

(Women) Are you pregnant? If yes, give due date

(Women) Are you nursing?

Sputum production (phlegm)

Do you use tobacco in any form? If yes, how much

Do you use alcoholic beverages (more than 2 drinks per day)?

Do you use recreational drugs? If yes, what and how often?

Do you use electronic cigarettes (vape)? If yes, how often?

Do you have or have you ever had any of the following:

GENERAL

Difficulty breathing while lying down

Tire easily, weakness

Marked weight change

Persistent fever

SKIN

Eruptions (rash) hives

Change in skin color

Visual change

Glaucoma

Dry Eyes

EARS

Loss of hearing

Ringing in ears

NOSE

Frequent nosebleeds

Sinus problems

THROAT

Soreness/hoarseness

Enlarged Tonsils

NERVOUS SYSTEM

Stroke (If yes, please date)

Headaches (chronic)

Convulsions/seizures

Numbness/tingling

Dizziness/fainting

Psychiatric treatment

RESPIRATORY

Tuberculosis

Emphysema

Asthma/hay fever

Persistent cough

Cough up bloody sputum

BLOOD

Bruise Easily

Anemia

Blood transfusion

Blood Disease

ENDOCRINE

Diabetes I or II. (If yes, please specify type)

Thyroid condition/goiter

HEART/BLOOD VESSELS

Rheumatic Fever

Heart Murmur

Chest pain/discomfort

Heart attack/trouble. (If Yes, please specify date)

Shortness of Breath

Swelling of ankles

High blood pressure

Congenital heart disease

Mitral valve prolapse

Artificial heart valve

Pacemaker/defibrillator

Heart surgery. (If Yes, please specify date)

Other (If Yes, please specify)

BONE/MUSCLES

Arthritis/rheumatism

Artificial joints/limbs. (If Yes, please specify type)

DIGESTIVE SYSTEM

Hepatitis A, B, or C

Jaundice

Ulcers

Change in appetite

Black, bloody or pale stools

URINARY

Kidney disease

Increase in frequency of urination

Burning on urination

Urethral discharge

Bloody urine

Venereal Disease

OTHER

Radiation therapy. (If Yes, please specify what for)

Chemotherapy. (If Yes, please specify what for)

Tumors or growths

Cancer (If Yes, please specify)

HIV+ / Aids

Are you ALLERGIC or have you ever experienced any reaction to the following?

Local anesthetics (e.g. novocaine)

Barbiturates/sedatives/sleeping pills

Penicillin

Other antibiotics (list below)

Latex

Are you allergic to aspirin?

Codeine

Sulfa drugs

Other allergies

Are you taking any of the following?

Antibiotics/sulfa drugs

Blood thinners

Blood pressure medication

Thyroid medicine

Cortisone/steroids

Antihistamines/allergy drugs

Cold medications

Sedatives

Insulin/other diabetes drugs

Recreational drugs

Digitalis/other heart medications

Nitroglycerin

Aspirin

Other medications

Does dental treatment make you nervous?

Do you have or have you ever had any of the following?

MOUTH

Bleeding, sore gums

Unpleasant taste/bad breath

Burning tongue/lips

Frequent blisters, lips/mouth

Swelling/lumps in mouth

Ortho treatments (braces)

Biting cheeks/lips

Clicking/popping jaw

Difficulty opening or closing jaw

TEETH

Loose teeth

Sensitive to hot

Sensitive to cold

Sensitive to sweets

Sensitive to biting

Food impaction

Clenching /grinding

Shifting of teeth

Change in bite

Do you have/noticed any of the following symptoms?

Mouth breathing

Dry mouth / throat

Snoring

Daytime fatigue

Restlessness

Irritability

ORAL HYGIENE

Toothbrush

Electric toothbrush

Bristles on my brush are:

Do you use dental floss?

Do you water floss?

Fluoride Rinse

Other types of oral hygiene

Use of Oral Appliances

CPAP Machine

Snoring Appliance

Night guard / Occlusal Guard

Athletic guard

Orthodontic retainer

Any other oral appliances?

By checking the box below I agree that to the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health or change in my medication, I will inform the dentist at the next appointment.

Agree*


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