METROTOWN DENTAL CLINIC

MEDICAL HISTORY

The following information is required to thoroughly diagnose any condition and to give the highest possible standards of professional services.
All information will be kept strictly confidential.

Name:

Birthdate (MM/DD/YR):

Physician's name:

Physician's phone number:

1. Have you ever had a serious illness or are you under the care of a physician now?

Yes

IF YES: What illness and for how long?

2. If you use any medicine on a regular basis, please list:

3. Have you ever had any of the following: (Please check if applicable)

4. Have you experienced any unusual or allergic reaction to any of the following:

9. If there is a history of family disease, what is it?

10. *For Women:*	Yes	No
a) Are you pregnant?
b) Are you nursing?
c) Are you taking birth control pills?

	Referred by:
	Website
	Other

Signature (draw with mouse/stylus/finger to sign)::

Reset Signature

Date:

PATIENT DENTAL HISTORY

Name:

Reason for this visit:

When was your last dental visit:

What was done then:

Previous Dentist (name and location):

Have you had a complete series of dental x-rays taken at your last dentist:

How often do you brush your teeth:

How often do you floss your teeth:

Do you use an electric or manual toothbrush:

What dental condition concerns you at present?

If you could change anything about your smile, what would you change?

Office Financial and Insurance Policies
As a courtesy to our patients, it is our policy to bill dental plans directly. However, patients are advised that they must be aware of the details, limits and time intervals of their insurance, as they are ultimately responsible for all charges incurred.

Are you aware of the limits and details of your dental benefits policy?

Yes

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 diagnosis, the records of examination & treatment rendered to me or my child to third party payors and/or health practitioner. 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 to me or my dependents.

Signature (draw with mouse/stylus/finger to sign)::

Reset Signature

Date

HIPAA Compliant

Gastrointestinal Disease	Stomach ulcer / Acid reflux
Mental health disorder	Eating disorder
Rheumatic Fever	Sinus problems
Chest pain	Pacemaker
Heart surgery	Heart problems / Angina
Heart attack	High / Low blood pressure
Arthritis and joint pain	Anemia / Easily bruising
Fainting / dizzy spells	Diabetes
Hepatitis / Jaundice	Cortisone treatment
Cold sores	Back problems
Multiple sclerosis	Chemotherapy Radiation
Cancer (Pls specify)

	Yes	No
Swelling of ankles, feet, hands
Joint replacement / implants
Skin problems/ Hives/ Rashes
Tuberculosis
Thyroid Disease
Heart Disease
Epilepsy
Liver Disease
Kidney Disease
Stroke
Other

	Yes	No
Local Anesthetic
Penicillin
Sulfonamide (sulfa)
Any Metals
Aspirin
Latex
Codeine
Other

	Yes	No
5. Are you currently on any blood thinners?
6. Are you in a high-risk group or have you ever tested positive for:
Hepatitis
H.I.V
7. Do you or did you in the past receive intravenous or oral bisphosphonates (Fosamax, Actonel, Boniva)? If yes, for how long?
8. Have you ever been told that you need Antibiotics prior to Dental treatments?

	Yes	No
Do your gums bleed while brushing or flossing?
Are your teeth sensitive to hot or cold liquids/foods?
Do you feel pain in any of your teeth?
Do you have sores or lumps in or near your mouth?
Have you had any head, neck or jaw injuries?
Have you ever experienced any of the following problems in your jaw:
Clicking
Pain (joint, ear, side of face)
Difficulty/ discomfort in opening or closing
Difficulty/ discomfort in chewing
Do you have frequent headaches?
Do you clench or grind your teeth?
Do you bite your lips or cheeks frequently?
Have you noticed any loosening of your teeth?
Does food tend to get caught in between your teeth?
Have you ever had a periodontal treatment of your gums?
Have you ever worn a nightguard or other appliance?
Have you ever had prolonged bleeding after extractions?
Have you ever had problems sleeping/breathing or sinus problems?
Have you ever been told you snore?
Have you ever been tested or diagnosed with sleep apnea? If so, when?
Do you wear partials or dentures?
Have you had orthodontic treatment?