Dental History Name*Date* Date Format: MM slash DD slash YYYY Reason for visit*Date of last cleaning Date Format: MM slash DD slash YYYY Last x-rays Date Format: 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 Have you ever been diagnosed with periodontal disease? When? Do you smoke? How long? How often? Do you use chewing tobacco? How long? How often? Night guard N/A Medical HistoryName of Medical Doctor*OfficeAre 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?Are you pregnant/do you think you might be pregnant?*YesNoMaybeExpected Due date Date Format: MM slash DD slash YYYY Have you ever taken a premedication?*For*Do you have any artificial joints?*Date of surgery Date Format: MM slash DD slash YYYY Have you ever/do you currently use recreational drugs or alcohol?*YesNoplease 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* Date Format: MM slash DD slash YYYY Do you have any other medical problems we need to be aware of?*Signature*Date* Date Format: 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”.