In Case Of Emergencey Notify:

Primary Insurance Company

Secondary Insurance Company

Date Of Birth Of Secondary Insurance Person

Your medical and dental health histories are essential for the determination and course of your treatment in our office. It is important that you complete this questionnaire accurately as it will become part of your office record. Be assured that it will be held in strict confidence.

MEDICAL HEALTH HISTORY

A. Please check if you have any of the following: (if yes to any of the following, please explain in space provided in section “B")

Known Allergies:

B. ADDITIONAL MEDICAL INFORMATION:

C. List any medications/vitamins/supplements you are currently taking, including aspirin.

Female patients only

DENTAL HEALTH HISTORY

PLEASE CHECK IF YOU HAVE ANY PROBLEMS WITH THE FOLLOWING BELOW: INDICATE WHERE AND HOW LONG

Have you ever been advised to take antibiotics before dental treatment?

YesNo

Have you had prolonged bleeding following any medical or dental treatment in the past?

YesNo

Are there any growths or sores spots in your mouth?

YesNo

Have you ever been diagnosed with periodontal disease? (Gum disease, Pyorrhea)

YesNo

Have you ever had dry or burning mouth?

YesNo

Have you ever had an allergic reaction to “freezing”? (Local Anaesthetic) If yes, describe:

Is any part of your mouth sore due to clenching or grinding of your teeth

YesNo

Have you had any difficult extractions in the past?

YesNo

I hereby state that the above medical history is, to the best of my knowledge, accurate and complete. If I ever have any change in my health, or if my medicines change, I will inform the doctor or hygienist at the next appointment without fail. If deemed advisable, I grant permission for my physician to be contacted for details and advice. I further authorize the taking of radiographs (x-rays) or other diagnostic measures appropriate for a thorough evaluation as well as the release of all pertinent information to my dental history (including X-rays) to any dentist or physician involved in my treatment and to my dental insurance company, where applicable.