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Medical & Dental History
Name
*
First name
M.I.
Last name
Phone
*
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Home
Email
*
Date of Birth
*
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Physician's Name
Physician's City
Purpose of Initial Visit
Date of Last Physical Exam
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Purpose of Last Dental Visit
Medications
*
Date of Last Dental Visit
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December
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Previous Dentist's Name
*
Previous Dentist's City
*
Date of Last Teeth Cleaning
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Frequency of Dental Visits
*
Allergies
*
Penicilin
Antibiotics
Anesthetics
Metals
Latex
Other
What other allergies should we be aware of?
Conditions
*
Heart Disease
Heart Murmur
Pacemaker
Arthritis
HIV
Hepatitis
Stomach
Kidney
Liver
Asthma
Thyroid
Rheumatic Fever
Artificial Joint/Prosthetics
Diabetes (Type I or II)
Radiation / Chemotherapy Treatment
Blood Disorders (i.e. leukemia, anemia, etc.)
Epilepsy or Seizures
High / Low Blood pressure (select)
Other
What other conditions should we be aware of?
Health Factors
*
Select all that apply.
Pregnancy or Potential Pregnancy
Tobacco Use
Alcohol Use
Other Controlled Substances
Previous Hospitalization Purpose
What was your previous hospitalization purpose?
Dental Goals
*
Select all that apply.
Teeth Whitening
Orthodontics
Pain Relief
Alleviate Bad Breath
Replacement of Missing Teeth
Replacement of Old Metal Fillings
Other
What are your other dental goals?
Known Conditions
*
Select all that apply.
Grind Teeth
Bleeding Gums
Bad Breath
Soreness in Jaw
Sensitivity to Heat, Cold, Sweet or Pressure
Loose, Shifted or Chipped Teeth
Food Impaction Between Teeth
Other
What are other known conditions?
Oral Hygiene Habits
*
The frequency of brushing (times per day).
Less than once
Once
Twice
More than twice
Brush Type
*
Manual
Electric
Frequency of Flossing
*
Less than once
Once
Twice
More than twice
Oral Treatment History
*
Orthodontics
Endodontics (Root Canal)
Gum Treatment/Surgery
Bridge Work
TMJ
Do you have any other health-related concerns?
Emergency Contact's Full Name
Emergency Contact's Phone
*
Emergency Phone number type
Mobile
Home
Relation
I attest to the accuracy of the information on this page.
Signed Date
Signature
*
Phone
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