Walnutcreekdental.net

Patient Name
DENTAL HISTORY
Patient Account No.
Medical Alert
Welcome! So that we may provide you with the best possible care please complete both sides of this medical/dental history form. All information is completely confidential. What is the reason for your visit today?
Date of Last Dental Visit
Last Dental Cleaning
Last Full Mouth X-rays
How often do you have dental examinations?
What other dental aids do you use? (Interplak, toothpick, etc.) Do you have any dental problems now?
Are any of your teeth sensitive to:
Have you ever had:
Have you noticed any mouth odors or bad tastes? Do you frequently get cold sores, blisters or Do your gums bleed or hurt?
Have your parents experienced gum disease Have you experienced:
Have you noticed any loose teeth or change Does food tend to become caught in between Difficulty in opening or closing the mouth? Difficulty in chewing on either side of the mouth? Clench or grind your teeth while awake or asleep? Are you satisfied with your teeth's appearance?
Would you like to keep all of your teeth all of your life? (pencils, pipe, pins, nails, fingernails) Do you feel nervous about having dental treatment? Have tired jaws, especially in the morning? Have you ever had an upsetting dental experience? Is there anything else about having dental treatment that you would like us to know?
FORM 015 (10-91)
1.800.925.2600
Copyright 1991 Pride Publishing Ltd.
Patient Name
MEDICAL HISTORY
Patient Account No.
Medical Alert
Have you been under the care of a medical doctor during the past two years? Have you taken any medication or drugs during the past two years? Are you taking any medication, drugs or pills now? Have you ever taken prescription medications for weigt loss (diet pills)? If yes, did you take any of the following: Fen-Phen (Fenfluramine-Phentermine) If yes to any of the above, did you have a medical exam for heart issues? 5. Are you aware of having an allergic (or adverse reaction) to any medication or substance?
Have you been a patient in the hospital during the past five years? Indicate which of the following you have had, or have at present. Check if using your keyboard or a pen, "yes" or "no" to each item.
Do you use more than two pillows to sleep? Have you lost or gained more than 1 0 pounds in the past year? Do you have or have you had any disease, condition, or problem not listed? 11. Women. Are you: Pregnant?
NO Taking birth control pills?
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission toask the respective health care provider or agency, who may release such information to you. I will notify the doctor ofany change in my health or medication. Copyright 1991 Pride Publishing Ltd.
FORM 015 (10.91)
1.800.925.2600

Source: http://www.walnutcreekdental.net/forms/EC5B9CF5d01.pdf