NEW PATIENT MEDICAL HISTORY - ProSites, Inc.



| PATIENT MEDICAL HISTORY |

|PLEASE CHECK OR CIRCLE THE FOLLOWING INFORMATION |

PATIENT NAME____________________________________________________BIRTHDATE__________________________

PHYSICIAN’S NAME________________________________________________OFFICE PHONE_______________________

FORMER DENTIST_________________________________________________OFFICE PHONE_______________________

DATE OF LAST DENTAL TREATMENT____________________FOR______________________________________________

1. ARE YOU CURRENTLY UNDER ANY SPECIAL MEDICAL TREATMENT? YES OR NO

IF YES, LIST CONDITIONS: ____________________________________________________________________________

|LIST ANY MEDICATION YOU ARE TAKING |

|AND REASON FOR TAKING THEM |

2. WOMEN ONLY:

A. ARE YOU PREGNANT OR THINK YOU MAY BE? YES OR NO _________________________________________

B. ARE YOU NURSING? YES OR NO

C. ARE YOU TAKING ORAL CONTRACEPTIVES? YES OR NO _________________________________________

D. ARE YOU TAKING MEDICATION FOR

OSTEOPOROSIS OR OSTEOPENIA? YES OR NO _________________________________________

3. ARE YOU ALLERGIC TO ANY OR HAVE HAD REACTIONS TO: __________________________________________

LOCAL ANESTHETICS (NOVOCAINE) YES OR NO __________________________________________

PENICILLIN OR TO ANY ANTIBIOTICS YES OR NO

SULFA DRUGS YES OR NO __________________________________________

LATEX GLOVES YES OR NO

ANY METAL (NICKEL, MERCURY, ETC.) YES OR NO __________________________________________

OTHER_________________________________________

____________________________________________________

4. DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING:

HISTORY OF SURGERIES:____________________________________________________________________________

ANY JOINT REPLACEMENTS (PINS & RODS ALSO)________________________________________________

YES NO YES NO YES NO

AIDS/HIV ? ? EPILEPSY ? ? BLEEDING PROBLEMS ? ?

ARTHRITIS ? ? GLAUCOMA ? ? RHEUMATIC FEVER ? ?

ASTHMA ? ? HEART MURMUR ? ? SINUS TROUBLE ? ?

ARTIFICAL HEART VALVE ? ? HEPATITIS ? ? SEXUALLY TRANS. DISEASE ? ?

CANCER TREATMENT ? ? DIABETES ? ? TUBERCULOSIS ? ?

CHRONIC COUGH ? ? DENTAL IMPLANT ? ? CARDIAC PACEMAKER ? ?

JOINT REPLACEMENT ? ? COLD SORES ? ? HI/LOW BLOOD PRESSURE ? ?

DRUG ABUSE PROBLEM ? ? ANEMIA ? ? PSYCHIATRIC TREATMENT ? ?

STROKE ? ? EMPHYSEMA ? ? OSTEOPOROSIS ? ?

5. DO YOU USE TOBACCO? ? YES ? NO HOW MUCH?_________________HOW LONG_______________

USED TOBACCO IN THE PAST? ? YES ? NO HOW MUCH?_________________ HOW LONG_______________

YES NO

6. HOW OFTEN DO YOU BRUSH AND FLOSS YOUR TEETH?_____________________USE A TOOTHPICK ? ? ?

7. DO YOU HAVE ANY DISCOLORATION OR SWELLING IN YOUR MOUTH? ? ?

8. DO YOUR GUMS BLEED? ? NO ? YES ARE YOUR TEETH PAINFUL? ? ?

9. CAN YOU CHEW WELL ON BOTH SIDES OF YOUR MOUTH? ? ?

10. DO YOU CLENCH/GRIND YOUR TEETH? ? YES ? NO DO YOU WEAR PARTIALS OR DENTURES? ? ?

I certify that I have read and understand the above information to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. I authorize release of any information including diagnosis and the records of any treatment rendered to my child or me during the period of dental care to third parties and/or health practitioners.

SIGNATURE______________________________________________________________DATE_______________________

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