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Brockportsmiles.com

DENT AL & ME DIC AL HIST ORY
Patient Name: ____________________________________________ Date: _______________________
DENTAL HISTORY
Have you experienced any of the fol owing (please check al that apply):
Rate your smile from 1 – 10: ____________ What would you change: _______________________________________
Does dental treatment make you nervous?  Yes  No Are you happy with past treatment?  Yes  No
Have you ever had a negative experience in a dental office?  Yes  No
Please explain: ________________________________________________________________________________________
Do you usual y have anesthesia with your dental treatment? ___________________________________________________
Have you had orthodontic work in the past? _____________________________________________ Dates: _____________
Have you had periodontal surgery? __________________________________________________ Dates: _______________
How long since you’ve seen a dentist? __________________________________________ Were X-Rays taken?  Yes  No
What was done at your last dental visit? ____________________________________________________________________
Have you lost any teeth?  Yes  No If so, why? _______________________________ Were they replaced?  Yes  No
How often do you brush? __________ Floss? __________ What type of toothbrush do you use?  Soft  Medium  Hard
MEDICAL HISTORY
Do you have or have you had any of the fol owing conditions (please check al that apply):  Anemia/Blood Disorder  Heart Disease/Attack/Surgery  Heart Stent  Sore/Enlarged Lymph Nodes  Psychosis  Slow Healing Mouth Sores  Unintentional Weight Gain or Loss  Other Conditions:_____________________________ Recurrent Il nesses: _______________________________________________________________________________________
MEDICATION INFORMATION
Are you taking any of these medications (please check al that apply):  Pre-medications for dental treatment  Tagament (cimetidine) or Prilosec (omeprazole)  Cardizem (diltiazem) or Calan, Isoptin (verapamil)  Diflucan (fluconazole) or Sporonox (itraconazole) Have you been treated with Bisphosphonate drugs (Fosamax, Aredia, Zometa, Actonel, Boniva)?  Yes  No If so, when did treatment begin: ________________________ End: ___________________________ Have you ever taken any prescription drugs such as fen-phen for weight loss?  Yes  No Do you consume grapefruit juice, grapefruits or grapefruit extract?  Yes  No 64 North Main Street • Brockport, NY 14420
office 585.637.6884 fax 585.637.7087 email info@brockportsmiles.com www.brockportsmiles.com
DENT MEDIC AL HISTORY
DENT AL & ME DIC AL HIST ORY
DENT AL & ME DIC AL HIST ORY
Patient Name: ____________________________________________ Date: _______________________
MEDICAL HISTORY CONTINUED
Physician Name: _______________________________________________ Phone #: ______________________________
Date of last health care exam: __________________ Do you have any drug al ergies? _____________________________
Have you been hospitalized in the last 5 years?  Yes  No If yes, reason: _____________________________________
Are you currently receiving care?  Yes  No If yes, nature of care: __________________________________________
Please list the names and phone numbers of the physicians what are currently providing you care:
Name: _____________________________________________ Phone: _________________________________________
Name: _____________________________________________ Phone: _________________________________________
Name: _____________________________________________ Phone: _________________________________________
Please list al medications (prescription or non-prescription) that you are currently taking and reason for medication:
Medication: _________________________________________ Reason: _________________________________________
Medication: _________________________________________ Reason: _________________________________________
Medication: _________________________________________ Reason: _________________________________________
Medication: _________________________________________ Reason: _________________________________________
Medication: _________________________________________ Reason: _________________________________________
Medication: _________________________________________ Reason: _________________________________________
Do you have any known al ergies (latex, etc.)? _______________________________________________________________
Other known al ergies? (i.e. pol en, etc.) ____________________________________________________________________
Do you drink:  public water  wel water  bottled water
Women:
Are you pregnant?  Yes  No Nursing?  Yes  No Taking birth control pil s?  Yes  No
Patient or Legal Guardian Signature: _____________________________________________________
64 North Main Street • Brockport, NY 14420
office 585.637.6884 fax 585.637.7087 email info@brockportsmiles.com www.brockportsmiles.com

Source: http://www.brockportsmiles.com/cmsAdmin/uploads/Dental-&-Medical-History.pdf