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Home
About Us
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Best Cosmetic Dentist in Moscow, ID
Invisalign Provider in Moscow, ID
Same-Day Crowns Near Me
Dental Implants
TOUR
PATIENT FORMS
Paperwork For Patients
Dental Benefits Plan
Contact Us
MY ACCOUNT
Dental History
Name
*
Date
*
MM slash DD slash YYYY
Reason for visit
*
Date of last cleaning
MM slash DD slash YYYY
Last x-rays
MM slash DD slash YYYY
Do you have any of the following? Check those that apply:
Sensitivity to hot/cold
Dry mouth
Bleeding gums
Jaw Pain
Discolored teeth
Grinding teeth
Mouth breathing
Lip or cheek biting
Removable retainers or dentures
Crowded teeth
Bad breath
Food collection
Swelling around teeth
Broken fillings
Loose teeth
Braces
Sore on lips
Sores inside mouth
Night guard
Have you ever been diagnosed with periodontal disease?
*
Yes
No
When?
Do You Smoke?
*
Yes
No
How long have you smoked?
How often do you smoke?
Do You Use Chewing Tobacco?
*
Yes
No
How long have you used chewing tobacco?
How often do you use chewing tobacco?
Medical History
Name of Medical Doctor
*
Office
Are you taking any medications at this time? Please list name and dosage
*
Are you allergic to any of the following? Check all that apply:
*
Penicillin
Latex
Codeine
Foods
Dental Anesthetic
Metals/other materials
N/A
Any other allergies we should be aware of?
Do You Have A Preferred Pharmacy?
Are you pregnant/do you think you might be pregnant?
*
Yes
No
Maybe
Expected Due date
MM slash DD slash YYYY
Have you ever taken a premedication?
*
Yes
No
For
*
Do you have any artificial joints?
*
Date of surgery
MM slash DD slash YYYY
Have you ever/do you currently use recreational drugs or alcohol?
*
Yes
No
please indicate what, when, and how much:
*
Do you have any of the following? Check those that apply
*
Abnormal blood pressure
Arthritis or rheumatism
Asthma or hay fever
Blood disease or anemia
Chemotherapy/radiation therapy
HIV/AIDS
Jaundice
Rheumatic fever
Sinus trouble
Ulcers
Prolonged bleeding
Hepatitis (List type)
Chronic cough
Congenital heart lesions
Epilepsy
Glaucoma
Head injury
Kidney disorder
Leukemia
Stroke
Thyroid condition
Tumors or growths
Fainting spells
STD's (List type)
Heart disease
Heart murmur
Heart pacemaker
Sleep apnea
Mitral valve prolapse
Multiple sclerosis
Parkinson's disease
Psychiatric treatment
Tuberculosis or lung disease
Excessive urination
Excessive thirst
Diabetes (List type)
Heart Attack
N/A
Date of Heart Attack
*
MM slash DD slash YYYY
Do you have any other medical problems we need to be aware of?
*
Signature
*
Date
*
MM slash DD slash YYYY
I certify that this is an accurate history of my health.
*
“I certify that this is an accurate history of my health”.
Δ
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Home
About Us
Meet Our Staff
Best Cosmetic Dentist in Moscow, ID
Invisalign Provider in Moscow, ID
Same-Day Crowns Near Me
Dental Implants
TOUR
PATIENT FORMS
Paperwork For Patients
Dental Benefits Plan
Contact Us
MY ACCOUNT