PATIENT NAME ...



PATIENT NAME______________________________________________________DATE____________

|DENTAL HISTORY |

Do you have a specific dental issue you would like to discuss? YES / NO

Explain________________________________________________________________________________

What type of toothbrush do you use? □ MANUAL – Soft / Medium / Hard □ ELECTRIC_____________________

How often do you brush? ________x per day How often do you floss? ________x per week

Do you ever have clicking, popping or discomfort in your jaw joint? YES / NO

Did you have orthodontics in the past? YES / NO If yes, do you wear retainers? YES / NO

Would you like cosmetics options discussed with you? YES / NO

Explain________________________________________________________________________________

|MEDICAL HISTORY |

Are you under a physician’s care now? YES / NO

Explain________________________________________________________________________________

Have you ever had any serious illness or hospitalized YES / NO

Explain________________________________________________________________________________

Have you ever been instructed to take antibiotics BEFORE dental procedures? YES / NO

Do you now have or ever had any of the following? YES / NO

□ Artificial Heart Valve

□ History of Infective Endocarditis

□ Congenital (present from birth) Heart Condition that required surgery

□ Joint replacement If Yes, when?____________

Are you taking any medications? What?__________________________________________________ YES / NO

Do you have any allergies (medication, latex, acrylics, pollen, dander, etc) What?________________________ YES / NO

WOMEN – Are you pregnant? How many weeks?__________________________________________ YES / NO

|Significant Findings |

| |

X__________________________________DATE______ X_____________________________DATE__________

PATIENT SIGNATURE DOCTOR SIGNATURE

|MEDICAL UPDATES |

DATE CHANGES REVIEWED BY

_______ ___________________________________________________________ Dr. _____________

_______ ___________________________________________________________ Dr. _____________

_______ ___________________________________________________________ Dr. _____________

_______ ___________________________________________________________ Dr. _____________

_______ ___________________________________________________________ Dr. _____________

_______ ___________________________________________________________ Dr. _____________

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