Best Dentist in Fremont CA | Patient Medical History Form

Patient Medical History

Physician *

Office Phone *

Date of last exam *

Are you under medical treatment now? *

Have you ever been hospitalized for any surgical operation or serious illness within the last 5 year? If yes. Please explain *

Explain here *

Are you taking any medication(s) including non-prescription medicine? If yes. what medication(s) are you taking? *

what medication(s) are you taking? *

Have you ever taken Fen-Phen/Redux? *

Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates? *

Do you use tobacco? *

Do you use controlled substances? *

Do you have or have you had any of the following?

High Blood Pressure
Heart Attack
Rheumatic Fever
Swollen Ankles
Fainting / Seizures
Asthma
Low Blood Pressure
Epilepsy / Convulsions
Leukemia
Diabetes
Kidney Diseases
AIDS or HIV Infection
Thyroid Problem
Acid Reflux
Heart Disease
Cardiac Pacemaker
Heart Murmur
Angina
Frequently Tired
Anemia
Emphysema
Cancer
Arthritis
Joint Replacement or Implant
Hepatitis / Jaundice
Sexually Transmitted Disease
Stomach Trubles / Ulcers
Osteoporosis
Chest Pains
Easily Winded
Stroke
Hay Fever / Allergies
Tuberculosis
Radiation Therapy
Claucoma
Recent Weight Loss
Liver Disease
Heart Trouble
Respiratory Problems
Mitral Valve Prolapse
Other

Other Diseases *

Are you wearing contact lenses? *

Are you allergic to or have you had any reactions to the following?

Local Anesthetics (e.g. Novocain)
Penicillin or any other Antibiotics
Sulfa Drugs
Barbiturates
Sedatives
Lodine
Aspirin
Any Metals (e.g. nickel, mercury, etc)
Latex Rubber
Other

Other (please list) *

Do you have a persistent cough or throat clearing not associated with a known illness (lasting more 3 weeks)? *

Women Only:

Are you pregnant or think you may be pregnant?
Are you nursing?
Are you taking oral contraceptives?

Patient Dental History

Name of Previous Dentist and Location *

Date of Last Exam *

Do your gums bleed while brushing or flossing? *

Are your teeth sensitive to hot or cold-liquids/foods? *

Are your teeth sensitive to sweet or sour liquids/foods? *

Do you feel pain to any of your teeth? *

Do you have any sores or lumps in or near your mouth? *

Have you had any head, neck or jaw injuriesv *

Have you ever experienced any of the following problems in your jaw? *

Clicking
Pain (joint, ear, side of face)
Difficulty in opening or closing
Difficulty in chewing
No

Do you have frequent headaches? *

Do you clench or grind your teeth? *

Do you bite your lips or cheeks frequently? *

Have your ever had any difficult extractions in the past? *

Have you ever had any prolonged bleeding following extractions? *

Have you had any orthodontic treatment? *

Do you wear dentures or partials? If yes, date of placement *

Fill date of placement *

Have you ever received oral hygiene instructions regarding the care of your teeth and gums? *

Do you like your smile? *

Authorization and Release

Authorization and Release *

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or ezamination rendered to me or my child during the period of such Dental care to third party payors and / or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Signature of patient (or parent / guardian if minor) *

Date *