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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