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 HistoryName 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?*YesNoMaybeExpected 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* Reset signature Signature locked. Reset to sign again 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