Medical History Form - Dentist in Miami, FL - Endodontist - Periodontist

Name *

First

Last

Home Phone *

Business/Cell Phone

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Occupation *

Height *

Weight *

Date of Birth *

SS# or Patient ID *

Emergency Contact

Relationship *

If you are completing this form for another person, what is your relationship to that person?

Your Name *

First

Last

Relationship

Do you have any of the following diseases or problems:

Active Tuberculosis

Yes
No
Don't Know

Persistent cough greater than a 3 week duration

Yes
No
Don't Know

Cough that produces blood

Yes
No
Don't Know

Been exposed to anyone with tuberculosis

Yes
No
Don't Know

Dental Information

1. Do your gums bleed when you brush or floss?

Yes
No
Don't Know

2. Are your teeth sensitive to cold, hot, sweets or pressure?

Yes
No
Don't Know

3. Does food or floss catch between your teeth?

Yes
No
Don't Know

4. Is your mouth dry?

Yes
No
Don't Know

5. Have you had any periodontal (gum) treatments?

Yes
No
Don't Know

6. Have you ever had orthodontic (braces) treatment?

Yes
No
Don't Know

7. Have you had any problems associated with previous dental treatment?

Yes
No
Don't Know

8. Is your home water supply fluoridated?

Yes
No
Don't Know

9. Do you drink bottled or filtered water?

Yes
No
Don't Know

10. Are you currently experiencing dental pain or discomfort?

Yes
No
Don't Know

11. Do you have earaches or neck pains?

Yes
No
Don't Know

12. Do you have any clicking, popping or discomfort in the jaw?

Yes
No
Don't Know

13. Do you brux or grind your teeth?

Yes
No
Don't Know

14. Do you have sores or ulcers in your mouth?

Yes
No
Don't Know

15. Do you wear dentures or partials?

Yes
No
Don't Know

16. Do you participate in active recreational activities?

Yes
No
Don't Know

17. Have you ever had a serious injury to your head or mouth?

Yes
No
Don't Know

Date of your last dental exam? *

What was done at that time? *

Date of last dental x-rays? *

What is the reason for your dental visit today?

How do you feel about your smile?

Please mark (tick) your response to indicate if you have or have not had any of the following diseases or problems

Are you now under the care of a physician?

Yes
No
Don't Know

Are you in good health?

Yes
No
Don't Know

Has there been any change in your general health within the past year?

Yes
No
Don't Know

Have you had a serious illness, operation or been hospitalized in the past 5 years?

Yes
No
Don't Know

Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Yes
No
Don't Know

Physician Name: *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

If yes, what was the illness or problem?

If yes, what condition is being treated?

If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements: