ARTHUR FAMILY DENTISTRY



Dental HistoryReason for visit today________________________________________________________________________Former Dentist__________________________________ City/State___________________________________Date of last dental Cleaning________________________ Date of last dental x-rays_______________________What type of water do you have? Well ____ City ____Do you take fluoride supplements? Yes ____ No ____ What type of tooth brush are you using? Hard____ Medium ____ Soft____ Electric____ Yes___ No___ Bad Breath Yes___ No___ Gum swollen or tenderYes___ No___ Periodontal treatmentYes___ No___ Bleeding GumsYes___ No___ Jaw pain or tirednessYes___ No___ Sensitivity coldYes___ No___ Blisters on lips/mouthYes___ No___ Lip or cheek bitingYes___ No___ Sensitivity hotYes___ No___ Burning Sensation on tongueYes___ No___ Loose teethYes___ No___ Sensitivity sweetsYes___ No___ Clicking or popping in jawYes___ No___ Lost fillingsYes___ No___ Sensitivity bitingYes___ No___ Dry MouthYes___ No___ Mouth breathingYes___ No___ Sores or growths in mouthYes___ No___ Food collection between teethYes___ No___ Mouth pain, brushingYes___ No___ Smokeless tobaccoYes___ No___ Foreign ObjectsYes___ No___ Orthodontic treatmentYes___ No___ Tobacco habitYes___ No___ Grinding teethYes___ No___ Partial(s) or Denture(s)Medical History Physician’s Name______________________________________________________Yes___ No___ AidsYes___ No___ Hay FeverYes___ No___ Recent Weight LossYes___ No___ AnemiaYes___ No___ HeadachesYes___ No___ Respiratory DiseaseYes___ No___ Anxiety/Panic AttacksYes___ No___ Head/Neck injuryYes___ No___ Rheumatic FeverYes___ No___ Arthritis, RheumatismYes___ No___ Heart MurmurYes___ No___ Scarlet FeverYes___ No___ Artificial Heart ValvesYes___ No___ Heart ProblemsYes___ No___ ShinglesYes___ No___ Back ProblemsYes___ No___ HemophiliaYes___ No___ Sickle Cell DiseaseYes___ No___ Bleeding AbnormallyYes___ No___ Hepatitis Type____Yes___ No___ Shortness of BreathYes___ No___ Blood Thinner/AspirinYes___ No___ HerpesYes___ No___ Sinus TroubleYes___ No___ Blood TransfusionYes___ No___ High Blood PressureYes___ No___ Skin RashYes___ No___ Blood DiseaseYes___ No___ High CholesterolYes___ No___ Special DietYes___ No___ Bruise EasilyYes___ No___ HIV PositiveYes___ No___ Spina BifidaYes___ No___ CancerYes___ No___ Hives or RashYes___ No___ StrokeYes___ No___ Chemical DependencyYes___ No___ Hormone ReplacementYes___ No___ Swelling of Feet/AnklesYes___ No___ ChemotherapyYes___ No___ Hypoglycemia Yes___ No___ Swollen Neck GlandsYes___ No___ Chest PainsYes___ No___ JaundiceYes___ No___ Tobacco HabitYes___ No___ Circulatory ProblemsYes___ No___ Jaw PainYes___ No___ Smokeless TobaccoYes___ No___ Congenital Heart LesionsYes___ No___ Joint ReplacementYes___ No___ Thyroid ProblemsYes___ No___ ConvulsionsYes___ No___ Kidney DiseaseYes___ No___ TonsillitisYes___ No___ Cortisone MedicineYes___ No___ LeukemiaYes___ No___ TuberculosisYes___ No___ Cough, persistent or bloodyYes___ No___ Liver DiseaseYes___ No___ Tumor or growth on head/neckYes___ No___ DiabetesYes___ No___ Low Blood PressureYes___ No___ UlcerYes___ No___ Drug AddictionsYes___ No___ Mitral Valve ProlapseYes___ No___ Venereal DiseaseYes___ No___ EmphysemaYes___ No___ Oral ContraceptivesYes___ No___ Weight loss, unexplainedYes___ No___ Excessive BleedingYes___ No___ OsteoporosisYes___ No___ Chronic DiseaseYes___ No___ Excessive ThirstYes___ No___ Pacemaker Yes___ No___ Do you wear contacts? Women: Yes___ No___ EpilepsyYes___ No___ Are you Pregnant? Yes___ No___ Fainting or dizzinessYes___ No___ Are you Nursing? Yes___ No___ Glaucoma 1047755827395For Office Use OnlyFor Office Use Only476253931920To the best of my knowledge, the questions on the 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 or dental status._________________________________________________________________________________________________Signature or patient/Guardian DateTo the best of my knowledge, the questions on the 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 or dental status._________________________________________________________________________________________________Signature or patient/Guardian Date3638550621665Allergies□Acrylic □ Latex□Aspirin □ Local Anesthetic□Barbiturates (Sleeping Pills) □ Metal□Codeine □ Penicillin□Iodine □Sulfa□Other ________________________________________________________________00Allergies□Acrylic □ Latex□Aspirin □ Local Anesthetic□Barbiturates (Sleeping Pills) □ Metal□Codeine □ Penicillin□Iodine □Sulfa□Other ________________________________________________________________47625621030MedicationsList any medications you are currently taking:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________00MedicationsList any medications you are currently taking:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________476256275070Date updated Initials Date updated Initials ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ Date updated Initials Date updated Initials ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ________________ ................
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