GENERAL HEALTH INFORMATION

Date:

GENERAL
HEALTH INFORMATION

PATIENT NAME:

BIRTH DATE:

AGE:

DENTAL HISTORY

1.Reason for Visit / Main Concern? Check-Up Cleaning Toothache

Other

2.Are there other conditions of which we should be aware? YES NO

If yes, please specify:

3.When did you last visit a dentist?

4.What treatment was performed?

5.Was the treatment completed?

6.When were dental x-rays taken?

7.Did you have a cleaning ? YES NO

8.Have you had gum (periodontal) treatment? YES NO

9.Have you ever had prolonged bleeding after an extraction? YES NO
If yes, please specify:

10.Have you had any problems with past dental treatment? YES NO
If yes, please specify:

11.Do you grind your teeth, clinch your jaws, or have symptoms near your ears such as clicking, popping, pain or locking open? YES NO
If yes, please specify:

12.Have you ever been diagnosed or treated for TMD (Temporomandibular Joint Dysfunction) sometimes called TMJ? YES NO
If yes, please specify:

13.Do your gums bleed easily? YES NO

14.Do you feel you have bad breath? YES NO

15.Are your teeth sensitive to hot or cold? YES NO

16.Would you like your teeth whiter? YES NO

YES NO If no, please specify:

1. Are you under a Doctor's care at this time? YES NO

If yes, please specify:

Dr. Name:

Dr. Phone:

2.Are you allergic to penicillin, codeine, local anesthetics, tranquilizers or any other drugs or medicine?

3.Are you taking any medications at this time, including birth control? YES NO

If yes, please specify:

4.(Women) Are you pregnant now? YES NO If yes, how many months?

Are you nursing? YES NO

5.Are there any other health problems of which we should be advised? Please specify:

6.Do you have, or have you had, any of the following?

Please check "YES" or "NO"

Doctor Comments

Please check "YES" or "NO"

Doctor Comments

ARTIFICIAL HEART VALVE YES NO

HEPATITIS YES NO

AIDS/HIV+ YES NO

HIGH BL. PRESSURE YES NO

ANEMIA YES NO

JAUNDICE YES NO

ANGINA YES NO

JOINT REPLACEMENT YES NO

ARTHRITIS YES NO

KIDNEY DISEASE YES NO

ASTHMA YES NO

LATEX ALLERGY YES NO

BISPHOSPHONATE THERAPY YES NO

LIVER PROBLEMS YES NO

BLEEDING PROBLEMS YES NO

LOW BL. PRESSURE YES NO

CANCER YES NO

LUNG DISEASE YES NO

CHEMO/RAD THERAPY YES NO

PACEMAKER YES NO

COSMETIC SURGERY YES NO

PSYCHIATRIC CARE YES NO

DIABETES YES NO

RHEUMATIC FEVER YES NO

DIZZY SPELLS YES NO

SINUS TROUBLE YES NO

DRUG ADDICTION YES NO

SLEEP APNEA YES NO

EMPHYSEMA YES NO

TOBACCO YES NO

EPILEPSY YES NO

STROKE YES NO

FAINTING YES NO

THYROID PROBLEMS YES NO

GLAUCOMA YES NO

TMD OR TMJ YES NO

HEART ATTACK/SURGERY YES NO

TUBERCULOSIS YES NO

HEART MURMUR/PROBLEMS YES NO

VENEREAL DISEASE YES NO

To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. I further certify that I consent to taking x-rays and an oral examination.

Patient's signature (Parent if Patient is a Minor)

Date: