Dental History
Patient’s Name: ______Prefer to be called:______
Reason for today’s visit: ______
Former Dentist: ______Location (City): ______
Date of last dental care: ______Date of last x-rays: ______
Check if you have had problems with any of the following:
□ Bad breath□ Food collection between teeth□ Periodontal treatment□ Sensitivity to sweets
□ Bleeding gums□ Grinding or clenching teeth□ Sensitivity to cold□ Sensitivity when biting
□ Clicking or popping jaw□ Loose teeth or broken fillings□ Sensitivity to hot□ Sores or growths in mouth
How do you care for your teeth each day? ______
If you could make a change to your teeth, what would it be? ______
Have you ever experienced an adverse reaction during a medical or dental procedure? □ Y □ N
Other information about your dental health or previous treatment ______
Medical History
Physician’s name______Phone______
Date of last visit______Have you had any serious illnesses or operations? □ Y □ N
If yes, describe ______
Are you currently under physician care? □ Y □ N If yes, describe ______
Women: Are you pregnant? □ Y □ NNursing? □ Y □ NTaking birth control pills? □ Y □ N
Check if you have had any of the following:
□ Acid Reflux□ Cancer□ Glaucoma□ Psychiatric care
□ ADD/ADHD□ Chemical imbalance□ Headaches□ Rapid weight loss/gain
□ AIDS/HIV□ Chemotherapy□ Heart murmur□ Radiation treatment
□ Alzheimer’s □ Circulatory problems□ Hemophilia or abnormal bleeding□ Respiratory disease
□ Anemia□ Cortisone treatments□ Hepatitis□ Shortness of breath
□ Anxiety□ Cough, persistent□ High blood pressure□ Sinus Infections
□ Arthritis□ Cough up blood□ High cholesterol□ Skin rash
□ Artificial heart valves□ Depression□ Kidney disease/malfunction□ Snoring or Sleep Apnea
□ Artificial joints□ Diabetes□ Liver disease□ Stroke
□ Asthma□ Eating disorder □ Material allergies (latex, □ Swelling of feet or ankles
□ Autism□ Epilepsywool, metal, chemicals, etc) □ Thyroid problems
□ Back problems□ Fainting□ Mitral valve prolapse□ Tuberculosis
□ Bipolar□ Fibromyalgia□ Osteoporosis/osteopenia□ Ulcer or Colitis
□ Blood disease□ Food allergies□ Pacemaker/Heart surgery□ Venereal disease
□ Drug/Alcohol addiction
□ Cardiac (Heart) problems-describe: ______
□ Other conditions not listed ______
Alcoholic beverages per week ______Do you smoke or chew tobacco? □ Y □ N
Have you ever taken bisphosphonates (such as Fosamax or Actonel for Osteoporosis; or Zometa or Aredia for Cancer)? □ Y □ N
List any medications or drugs you currently are taking: ______
List any drug allergies: ______
Authorization
I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. If there is any change in my medical status, I will inform the dentist.
I authorize the use of anesthetics during the course of treatment knowing that adverse reactions may occur such as but not limited to prolonged or permanent numbness, increased heart rate, swelling, needle breakage, soreness, bruising, etc.
I authorize the use of photographs before, during, and after treatment to be used in diagnosis, communications with labs and insurance companies and other doctors, and for marketing or display purposes.
Patient (or Parent/Guardian) Signature ______Date ______
Michael E. Bass, DDS 1031 W. Williams Street, Suite 101Apex, NC27502 (919) 362-6789 Form revised 04/2012