medical & dental history
Esthetic Dental Medical & Dental History
Name____________________________________________ Today’s Date _______________
Last MI First
Age _____ Date Of Birth ____________Height ______Weight ______Rate Health 1-10______ Do you have or have you had any of the following diseases, conditions or medical procedures? (First read all conditions in the list, then circle either “Yes” answers or “No” answers to the left) Any troubles, surgeries, defects, with these major organs:
Y N Heart
: Attack, Angina/Pain, Murmur / MVP or other defect, Rapid Beat / Arrhythmias, Congestive Failure,
Pacemaker, Surgeries: Bypass,Valve Replacement _______________________________________________
Y N Lung
: Asthma, Emphysema, Short of Breath, Cancer, TB, Other __________________________________________
Y N Liver
: Hepatitis, Jaundice / Cirrhosis, Enlargement, Cancer, Surgeries, Damage due to Alcohol or Drugs___________
Y N Kidney / Bladder:
Stones, Cancer, Surgeries: Transplant, Removal, Non-Functioning__________________________
Please summarize any other surgeries or further details from above:________________________________________________
______________________________________________________________________________________________________ Do you have or have you had any of the following diseases, conditions or medical procedures?
No blanks, and please circle appropriate selection
where more than one is listed.
Y N Blood Pressure, High or Low
Y N Clotting / Bleeding Problems / Vascular Problems
Y N Anemia: Iron , Pernicious(B-12), Sickle Cell Y N Head Injuries Y N Stroke: Major, TIA’s (mini)
Y N Thyroid: Hyper (overactive) or Hypo (underactive)
Y N Eye, Ear, Nose, Throat or Sinus Problems
Y N Arthritis, Rheumatism; Back, Neck Pain
Y N Stomach, GI : IBD, GERD, Ulcers, Colitis, Celiac Disease
Medicines & Drug Allergies
Y N Allergies To Any Medicines
(List. Include Antibiotics, Pain Killers, Local Anesthetics):_________________________
Y N Do You Have A Latex Allergy
Y N Have You Taken Any Prescription Steroids For More Than 2 Weeks in the Last 2 Years?_________________________
Y N Do You Take Any BLOOD THINNERS, Including Daily Aspirin?____________________________________________
Y N Do You Take Any Medicines For Osteoporosis? (please circle) alendronate (Fosamax), pamidronate (Aredia),
ibandronate (Boniva), zoledronate (Zometa), risedronate (Actonel), etidronate (Didronel)
Y N Are You Pregnant? How Long? _______________
Y N Are You Nursing?
Y N Are You Taking Birth Control Pills How Many Children Do You Have? ________________ ___________Patient Please Initial Here
Page 1 of 2
Please List All Medications You Take:
Doctor’s Notes: Dental Information:
What is Your Main Dental Concern?_________________________________________________________________________
Approx. Date & Reason For Last Dental Visit _________________________________________________________________
Y N Are You Satisfied With Your Previous Dental Care? _______________________________________________________
Y N Are You In Pain Now? If so, does it keep you awake at night? ___________
Y N Are Your Teeth Sensitive to: _____Hot _____Cold?
Y N Do You Use a Toothpaste With Tartar Control or Whitening Additives?
Y N Are You Aware of Any Clenching or Tooth Grinding?
Y N Any Pain In Jaw Muscles or Around Your Ears?
Y N Do Your Jaws Click or Pop?
Y N Any Difficulty Opening or Closing Jaws?
Y N Do You Currently Wear a Biteguard at Night? How Old is the Biteguard? ________yrs
Y N Do Your Gums Bleed? Whenever I Brush_____ Whenever I Floss______
Y N Past Orthodontic Treatment (braces)? Approximate Age Of Treatment _________
Y N I Am Interested in Orthodontics
Y N Do You Wear a Removable Partial Denture or Complete Denture? When Was It Made_________ Last Reline_________
If so: Y N Are You Interested in Discussing How Dental Implants Can Be An Alternative Solution?
I usually brush ______________times per day and floss__________________times per _________________ On the lines below, please place a check mark to indicate how interested you are in learning how cosmetic dentistry can improve
your smile, and please rate your smile:
Little Interest In Esthetic Dentistry______________________________________________________________Very Interested
Please Rate Your Smile: Not Pleased____________________________________________________________Very Pleased
I Have Questions About: ____ Porcelain Veneers _____All Porcelain Crowns ____Tooth Colored Fillings, Inlays, Onlays.
Doctor’s Signature _____________________________________________
Authorization For Treatment
I authorize the doctor and staff to perform any necessary services needed during dental diagnosis and treatment. I understand the above
information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform
this office of any changes to the information I have provided.
Print Patient Name____________________________________________________
Signature____________________________________________________________ Date / /
patient, or parent, or legal guardian page 2 of 2
The Center for Psychotropic Drugs and Children Health and Health Care in Schools A 2007 Update The School of Public Health & Health Services December 2007 THE GEORGE WASHINGTON UNIVERSITY References Background The safe and effective use of medications for the treatment of certain medical conditions and1 National Association of School Nurses. Position statemen
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