Ken Copeland Family Dentistry
Ken Copeland Family Dentistry
Dental & Medical History
Please answer all questions completely.
Dental Information
When was your last dental visit? ___________________
Who was your last dentist? _______________________
What was done at your last dental visit? _____________
_____________________________________________
Do you have any areas of concern? _________________
_____________________________________________
Is there anything you would like to change about your teeth or the appearance of your teeth? _____________
_____________________________________________
Are you interested in bleaching/whitening your teeth? _____________________________________________
Do you clench or grind your teeth? _________________
Does your jaw click or pop or lock? ________________
Do you have discomfort, soreness, or lumps in the muscles on your face or around your ear? __________
Do you have frequent headaches, neck aches or shoulder aches? ______________________________________
Does food get caught in your teeth? ________________
Are your teeth sensitive to sweets, pressure, hot or cold? _____________________________________________
Have you noticed your gums bleeding or hurting?
_____________________________________________
Have you had gum treatment or surgery? ____________
Do you need to pre-medicate with antibiotics? _____________________________________________
Have you noticed that you have bad breath? __________
Have you had orthodontic work (braces)? ____________
Are any of your teeth loose, tipped, shifted or chipped? _____________________________________________
Are you satisfied with any crowns (caps), bridges, implants or dentures that you have? _______________
Have you been told that you snore? ________________
Medical Information
Name of your physician: ________________________
Date of your last physical: _______________________
List of medications you are presently taking: ________
__________________________________________________________________________________________
List any vitamins, supplements, etc… you are taking on a regular basis: _______________________________
_____________________________________________
List all hospitalizations in the past five years: _________
__________________________________________
Do you use tobacco in any form? __________________
Do you consume alcoholic beverages? ______________
Do you use other controlled substances? _____________
Please circle the following conditions that you have or have had in the past:
Allergies: Codeine, Penicillin, Latex, Vinyl
Other: _________________________________
_____________________________________________
Arthritis or Rheumatism
Artificial Joints
Asthma
Blood Disorders
Anemia
Leukemia
Cancer
Chemotherapy
Radiation Treatment
Diabetes
Dizziness/Fainting
Epilepsy/Seizures
Excessive Bleeding
Glaucoma
Head Injuries
Heart Disease
Mitral Valve Prolapse
Pacemaker
Heart Murmur
Hepatitis
High Cholesterol
High Blood Pressure
HIV/AIDS
Jaundice
Kidney Disease
Liver Disease
Mental or Nervous Disorders
PTSD/Anxiety Disorders
Pregnancy (current)
Respiratory Problems (COPD, emphysema)
Rheumatic Fever
Sinus Problems
Stomach Problems/Ulcers
Stroke
Tuberculosis
Tumors or Growths
Venereal Disease
Other: _______________________________________
None of the Above
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