Austin Family Dentist



■ Medical History ■

Patient’s Name:_____________________________________DOB____________ Today’s Date_____________

Physician’s Name:__________________________ Physician’s Phone:_________________________________

List ALL medications currently taking (including supplements):_______________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

Prosthetic Heart Valve, Joint Replacement (i.e. Hip, Knee, Ankle, etc)? ❑ Yes ❑ No Date:___________________

Told that you need pre-medication prior to dental treatment: ❑ Yes ❑ No _______________________________

Blood Thinners: ❑ Baby Asprin ❑ Asprin ❑ Plavix ❑ Coumadin ❑ Predaxa ❑Other______________________

Allergies: ❑ Latex ❑ Metals ❑ Penicillin Other______________________________________________

Bisphosphonate Use (Osteoporosis Meds): ❑ Boniva ❑ Actonel ❑ Zometa ❑ Other______________________

Females: ❑ Birth Control Medication ❑ Pregnant: # Weeks_________ Are you Nursing? ❑Y ❑N

| Y/N Conditions |Y/N Conditions |Y/N Conditions |Y/N Conditions |

|❑ ❑ Anemia |❑ ❑ Diabetes |❑ ❑ Herpes |❑ ❑ HPV |

|❑ ❑ Abnormal Bleeding |❑ ❑ Difficulty Breathing |❑ ❑ HIV+ AIDS |❑ ❑ Kidney Problems |

|❑ ❑ Angina |❑ ❑ Drug Addiction |❑ ❑ Heart Attack |❑ ❑ Liver Disease |

|❑ ❑ Arthritis |❑ ❑ Emphysema |❑ ❑ Heart Disease/Surgery |❑ ❑ Pace Maker |

|❑ ❑ Asthma |❑ ❑ Fainting/Dizzy Spells |❑ ❑ Hemophilia |❑ ❑ Seizures |

|❑ ❑ Autoimmune |❑ ❑ Fever Blisters |❑ ❑ Hepatitis A, B or C |❑ ❑ Stroke |

|❑ ❑ Cancer/Radiation |❑ ❑ GI Disease or Reflux |❑ ❑ High Blood Pressure |❑ ❑ Thyroid Disease |

Other Medical Condition not mentioned above:____________________________________________________

Notes:____________________________________________________________________________________

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■ Dental History ■

| Y/N | Y/N | Y/N | Y/N |

|❑ ❑ Sensitive Teeth |❑ ❑ Jaw Pain (TMJ) |❑ ❑ Bleeding Gums |❑ ❑ Bad Breath |

|❑ ❑ Discolored Teeth |❑ ❑ Clenching/Grinding |❑ ❑ Periodontal Disease |❑ ❑ Tobacco Use |

|❑ ❑ Dry Mouth |❑ ❑ Cracked Teeth |❑ ❑ Tooth Trauma |❑ ❑ Crooked Teeth |

Other Dental Conditions not mentioned above:____________________________________________________

I understand the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

Signature: _____________________________________________ Date: ______________________________

Dentist :_______________________________________________ Date:_______________________________

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