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Dental HistoryReason for today’s visit____________________________________________________________________________________Former Dentist __________________________Date of last dental visit _______________Date of last X-rays _______________469582517145Are you allergic to any of the following?__ Aspirin __ Penicillin __ Codeine __ Acrylic __ Metal __ Latex __Sulfa Drugs __ Local Anesthetics__ Other ____________________________________________Women Are you…__ Pregnant/Trying to get pregnant?__ Nursing? __ Taking oral contraceptives?00Are you allergic to any of the following?__ Aspirin __ Penicillin __ Codeine __ Acrylic __ Metal __ Latex __Sulfa Drugs __ Local Anesthetics__ Other ____________________________________________Women Are you…__ Pregnant/Trying to get pregnant?__ Nursing? __ Taking oral contraceptives?Please mark “yes” or “no” to indicate if you have had any of the following:Bad Breath ___Yes ___ NoMouth Breathing ___Yes ___No Bleeding Gums ___Yes ___ No Mouth Pain, Brushing ___Yes ___NoBlisters on lips or mouth ___Yes ___NoOrthodontic treatment __Yes ___NoBlisters on lips or mouth ___Yes ___NoPain around ear __ Yes ___ NoBurning sensation on tongue ___Yes ___No Periodontal treatment ___Yes ___NoChew on one side of mouth ___Yes ___No Sensitivity to cold ___Yes ___NoCigarette, pipe or cigar smoking ___Yes ___No Sensitivity to heat___Yes ___NoClicking or popping jaw ___Yes ___No Sensitivity to sweets ___Yes ___NoDry Mouth ___Yes ___No Sensitivity when biting __Yes ___NoFingernail biting ___Yes ___NoSores or growths in your mouth ___ Yes ___NoFood Collection ___Yes ___NoGrinding___Yes ___No Gums swollen or tender ___Yes ___NoJaw pain or tiredness ___Yes ___No How often do you floss? ___________Lip or cheek biting ___Yes ___No Loose teeth or broken fillings ___ Yes ___No How often do you Brush? ___________Medical HistoryAre you under a physician’s care now? __ Yes __No If Yes _________________________________________________________Have you ever been Hospitalized or had a major operation? __ Yes __ No If yes:________________________________________________________Are you on a special diet? __ Yes __ No If yes:_________________________________________________________Have you have ever had a serious head or neck injury __ Yes __ No If yes:_________________________________________________________Are you taking any medications, pills or drugs? __ Yes __ No If yes:_________________________________________________________Do you take or have you taken, Phen-fen or Redux? __ Yes __ No If Yes:_________________________________________________________Do you use controlled substances? __ Yes __ No If yes:_________________________________________________________ Anxiety __ Yes __ No If yes:___________________________________________________ Do you use tobacco? __ Yes __No GERD/Acid Reflux__ Yes __ No Depression __ Yes __ NoHave you ever taken Fosamax, Bonive, Actonel or any other medications containing bisphonates? __ Yes __ No Have you ever had any serious illness not listed above? __Yes __ No If yes ____________Do you, or have you had any of the followAids/HIV Positive __Yes __ No Diabetes __ Yes __ No Hepatitis B or C __Yes __ No Rheumatic Fever __Yes __ NoAlzheimer’s Disease __Yes __ No Drug-Addiction __ Yes __ No Herpes __ Yes __ No Rheumatism __ Yes __ NoAnaphylaxis __ Yes __ NoEasily Winded __ Yes __ No High Blood Pressure __ Yes __ No Scarlet Fever __ Yes __ NoAnemia __Yes __ NoEmphysema __ Yes __ No High Cholesterol __ Yes __ No Shingles __ Yes __ NoAngina __ Yes __ NoEpilepsy or Seizures __ Yes __ No Hives or Rash __ Yes __ No Sickle Cell Disease __Yes __ NoArthritis/Gout __ Yes __ NoExcessive Bleeding __ Yes __ No Hypoglycemia __ Yes __ No Sinus Trouble __ Yes __ NoArtificial Heart Valve __ Yes __ NoExcessive Thirst __ Yes __ No Irregular Heartbeat __ Yes __ No Spina Bifida __ Yes __NoArtificial Joint __ Yes __ NoFainting spells/ Dizziness __ Yes __ No Kidney Problems __ Yes __No Stomach Disease __ Yes __NoAsthma __ Yes __ NoFrequent Cough __ Yes __ No Leukemia __ Yes __ No Intestinal Disease __Yes __ NoBlood Disease __ Yes __ NoFrequent Diarrhea __ Yes __ No Liver Disease __ Yes __ No Stroke __ Yes __ NoBlood Transfusion __ Yes __ No Frequent Headaches __ Yes __ No Low Blood Pressure __ Yes __ No Swelling of Limbs __ Yes __ NoBreathing Problems __ Yes __ NoGenital Herpes __ Yes __ No Lung Disease __ Yes __ No Thyroid Disease __ Yes __ NoBruise Easily __ Yes __ NoGlaucoma __ Yes __ No Mitral Valve Prolapse __ Yes __ No Tonsillitis __ Yes __ NoCancer __ Yes __ NoHay Fever __ Yes __ No Osteoporosis __ Yes __ No Tuberculosis __ Yes __ NoChemotherapy __ Yes __ NoHeart Attack/Failure __ Yes __ No Pain in Jaw Joints __ Yes __ No Tumors __ Yes __ NoChest Pains __ Yes __ NoHeart Murmur __ Yes __No Parathyroid Disease __ Yes __ No Growths __ Yes __ NoCold Sores/Blisters __ Yes __ NoHeart Pacemaker __ Yes __No Psychiatric Care __ Yes __ No Ulcers __ Yes __ NoCong Heart Disorder __ Yes __ NoHeart Trouble/Disease __ Yes __No Radiation Treatments __ Yes __ No Venereal Disease __ Yes __ NoConvulsions __ Yes __ NoHemophilia __ Yes __No Recent Weight Loss __ Yes __ NoCortisone Medicine __ yes __ NoHepatitis A __ Yes __No Renal Dialysis __ Yes __ NoComments:______________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status. _______________________________________________________________________________________Patient/Guardian Signature Date ................
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