Medical History

Indicate which of the following you have had or have at present.

* Pre-Med - Amox

Heart Murmur

* Pre-Med - Clind

Hepatitis

* Pre-Med - Other

High Blood Pressure

Allergies

HIV

Allergy - Hay Fever

Jaundice

Allergy - Latex

Kidney Disease

Allergy - Other

Liver Disease

Allergy - Penicillin

Low Blood Pressure

Allergy - Sulfa

Mental Disorders

Allergy - Aspirin

MVP

Allergy - Codeine

Nervous Disorders

Allergy - Erythro

Osteoporosis

Anemia

Pacemaker

Arthritis

Radiation Treatment

Artificial Joints

Respiratory Problems

Asthma

Rheumatic Fever

Blood Disease

Rheumatism

Cancer

Sinus Problems

Diabetes

Stomach Problems

Dizziness

Stroke

Epilepsy

Thyroid Problem

Excessive Bleeding

Tuberculosis

Fainting

Tumors

Glaucoma

Ulcers

Head Injuries

Venereal Disease

Heart Disease

* Other

A smoker or smoked previously

Ever been hospitalized (illness or injury)

FEMALE: Pregnant

FEMALE: Taking birth control pill

Presently being treated for any other illnesses

Taking dietary supplements

Taking medication for weight control (ie fen-phen)

Subject to frequent headaches

* Other: Please Explain Below if condition or alerts selected above needs further clarification.

Do you take antibiotic premedication for your dental visits? Yes No

If Yes, Please Explain:

Name of Physician and their Specialty :

Most Recent Physical Exam and Purpose :

List all medications taken within the last two years:

List all supplements, and/or vitamins taken within the last two years:

Smile Characteristics, Check all the apply:

Is there anything about the appearance of your teeth that you would like to change?

Have you ever whitened (bleached) your teeth?

Have you felt uncomfortable or self-conscious about the appearance of your teeth?

Have you been disappointed with the appearance of previous dental work?

Bite and Jaw Joint, Check all the apply:

You have problems with your jaw joint

You have problems chewing

Your teeth changed in the last 5 years, become shorter, thinner, or worn

Your teeth are crowding or developing spaces

You chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits

You clench your teeth in the daytime or make them sore

You have problems with sleep or wake up with an awareness of your teeth

You wear or have worn a bite appliance

Tooth structure, Check all the apply:

Cavities within the past 3 years

The amount of saliva in your mouth seems too little or you have difficulty swallowing any food

You notice or have holes (i.e. pitting, crates) on the biting surface of your teeth

Any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth

Grooves or notches on your teeth, chipped teeth, or had a toothache or cracked filling

Food gets caught between any teeth

Gum and Bone, Check all the apply:

Gums bleed when brushing or flossing

Treated for gum disease or were told you have lost bone around your teeth

Noticed an unpleasant taste or odor in your mouth

History or periodontal disease in your family

Experienced gum recession

Had any teeth become loose on their own (without injury), or have difficulty eating an apple

Experienced a burning sensation in your mouth

If any of the checked boxes need further explanation, please describe: