Patient name _______________________________________ date __________

PATIENT NAME _______________________________________ DATE __________
Primary reason for this dental appointment Examination Emergency Consultation Do you have a specific dental problem?______________________________________________________ Do you have dental examinations on a routine basis? Last visit____________________________________ Do you think you have active decay or gum disease? ___________________________________________ Do you brush and floss on a routine basis?____________________________________________________ Do your gums ever bleed? Discuss__________________________________________________________ Do you like your smile? Why______________________________________________________________ Would you like to replace any missing teeth? _________________________________________________ Do you want to keep remaining teeth? _______________________________________________________ Do you ever have clicking, popping, or discomfort in the jaw joint? ________________________________ Do you have any mercury fillings or dental work that you don’t like? _______________________________ If money were no object, what improvements would you make in your smile? ________________________ Date of last full mouth x-rays: ______________________________________________________________ Medical History Are you under a physician’s care now? Why?__________________________________________________ Have you ever been hospitalized or had a major operation? Discuss ________________________________ Have you ever had a serious injury to your head or neck? Discuss _________________________________ Are you taking any medications, pills or drugs? What?__________________________________________
Are you allergic to any medications or substances? Please check below_____________________________
Have you ever taken bisphosphanate medication (such as Actonel, Aredia, Boniva, Fosamax, Bonefos, Ostac, Skelid, Didronel) Yes No
Do you now have or have you ever had any of the following? Please check appropriate boxes.
*If yes to any of the starred conditions, please call prior to your appointment…premedication may be required
Hepatitis A (infectious) Y N
Artificial Heart Valve*
Heart Pace Maker*
Heart Surgery*
Artificial Joint*
Have you ever had any other serious illness not checked above? Discuss: _______________________ Do you with to talk to the dentist privately about any problems? ______________________________ I certify that I have read and understand the questions above. I acknowledge that my questions, if any, about the inquires set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form. Signature of patient: (Parent or Guardian if minor) ___________________________ AUTHORIZATION
I authorize my dentist and his/her designated staff to perform an oral examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the
taking of all x-rays required as a necessary part of this exam. In addition, if medically necessary, I authorize the release pf any authorization acquired in the course of
my examination and treatment.
Signature of patient (Parent or Guardian if minor) ______________________________
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I
may have regarding this Notice.
Signature of patient: (Parent or Guardian if minor) ________________________________ Date: ______________________

Source: http://www.drbrianfann.com/assets/docs/MedicalHistoryForm.pdf