Dental History

Patient's Name:
Reason for visit today?	Are you having discomfort today?
Date of last dental visit:	Date of last dental x-rays:
Former Dentist:	Address:	Phone#:

Please check if you have or have had problems with any of the following:

Any complications from prior dental work?Y N

If Yes explain:

Are you nervous about having dental work performed?

How often do you brush?

Other information regarding your dental health or past dental treatment you would like us to know?

Medical History

Physician’s name:		Phone #:
Address:		Date of Last Visit:
Are you currently under the care of a physician?		Y N
If Yes explain:

Please check if you currently have or have had any of the following:

If you have any medical condition not mentioned above please list

List any medications you are currently taking

List any medications that you have an allergy to:

For Women:
Are you pregnant? No Yes

If yes how far along?
Are you currently nursing? No Yes

Are you currently taking oral contraceptives? No Yes

I have reviewed the information on this questionnaire and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate dental treatment.

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