Confidential Patient Information

First Name:
Middle Initial:
Last Name:
Birthdate:

Medical History

Physician Name:
Date of Last Visit:
Phone:
Address:
City:
State:
Zip:

Please select YES or NO (If YES, please fill in details). Parents/Guardians please respond for minors.
Are you taking any medications/supplements/herbals?
Are you allergic to any medication/foods/latex/metals/acrylics/anestherics, etc.?
Do you have a history of a major illness?
Have you had any major operation?
Have you ever been involved in a serious accident?
Are you taking/have you taken bisphosphonates for osteoporosis or other bone diseases?
Do you chew or smoke tobacco products? If so, how long?
Please select YES or NO to any of the medical conditions below that you have had or currently have:
Abnormal Bleeding / Hemophilia?
Anemia?
Arthritis?
Asthma or Hayfever?
Bone Disorders?
Congenital Heart defect?
Diabetes?
Dizziness?
Epilepsy?
Gastrointestinal Disorder
Heart Problems / Heart Murmur?
Hepatitis / Liver Problems?
Herpes?
High Blood Pressure?
HIV / AIDS?
Kidney Problems?
Nervous Disorders?
Pneumonia?
Prolonged Bleeding?
Radiation / Chemotherapy?
Rheumatic Fever?
Sleep Apnea?
Tuberculosis?
Tumor or Cancer?
Are there any medical conditions we have not discussed that you feel we should be aware of?
Does your physician recommend premedicating with antibiotics prior to dental procedures?

Dental History

Dentist Name:
Last Dental Visit:
What concerns you most about your teeth?

Please select YES or NO (If YES, please fill in details). Parents/Guardians please respond for minors.
Are you happy with the appearence of your teeth?
Have you ever lost or chipped any teeth?
Have there been any injuries to face, mouth, or teeth?
Do you have any type of thumb or tongue habit?
Are you a mouth breather?
Do you snore loudly?
Have you been told you have a tongue thrust?
Are you aware of your jaw clicking or popping?
Do you grind or clench your teeth?
Have you ever experienced chronic ringing in your ears?
Are there any familial medical conditions we should know about?

Patients Under Age 16:
Height of parents? Mom: Dad:

Female Patients Only:
Are You Pregnant?
Has menstruation started (This is useful in monitoring/modifying growth of head and jaw bones)?
Signature: