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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