Medical History Update

YOUR DENTAL HISTORY

When was your last dental visit?

Former Dentist

Date of last dental x-ray?

Please check if you have/had:

Bad breath
Blisters on lips or mouth
Burning sensation on tongue
Chew on one side of mouth
Cigarette, pipe, or cigar smoking
Smokeless tobacco
Dry mouth
Food collection between teeth
Clench teeth
Grind teeth
Growths or sore spots in mouth
Gums swollen, tender, or bleeding
Head, neck, or jaw pain or aches
Lip or cheek biting
Loose teeth or broken fillings
Mouth breathing
Orthodontic treatment
Nitrous Oxide
Periodontal treatment

Do you have any sensitivity in your teeth?

Yes
No

What kind of sensitivity do you have?

Sensitivity to pressure
Sensitivity to cold
Sensitivity to hot
I'm not sure

How often do you brush?

How often do you floss?

Have you ever had an allergic reactions to Novocaine, local or general anesthetics?

Yes
No

If Yes, Please Explain

Have you had trouble from previous dental care?

Yes
No

If Yes, Please explain :

YOUR MEDICAL HISTORY

Do you have a primary physician?

Yes
No

Physician Name

Physician Phone

Have you ever had a blood transfusion?

Yes
No

If Yes, please describe

Please list any operations / surgeries you have had with their approx. dates?

Are you pregnant?

Yes
No

If pregnant, please indicate due date?

Are you nursing?

Yes
No

Are you on Birth Control Pills?

Yes
No

Please check if you have/had :

Type of Hepatitis?

Allergies

Please list any allergies you may have.

Medications

Please list any medications you are on

I have read and answered the above questions to the best of my knowledge.

Patient or Guardian Signature*

Name of Guardian (if signed by guardian)

First Last

Relationship to patient (if signed by guardian)

Proudly serving Valley Ranch, Coppell, Las Colinas and Irving, TX

Patient Information

Emergency Contact

YOUR DENTAL HISTORY

YOUR MEDICAL HISTORY

CONSENT FORM