Patient Medical History

In order to alleviate paperwork at the time of your first appointment, you are welcome to fill out and submit your information before your appointment. Fields with asterics (*) are mandatory fields and the form will not submit unless those spaces are filled. Please note, the form does not auto-save.

There are 2 forms to fill out, the Medical History Form (below) as well as the Patient Information Form. Once you have completed and submitted the form, a link to the second form will appear.

Patient Name *
Patient Name
Patient Birth Date *
Patient Birth Date
Medical Questionnaire
Name of Family Physician or Clinic
Name of Family Physician or Clinic
Phone Number of Family Physician or Clinic
Phone Number of Family Physician or Clinic
Date of Patient's Last Medical Examination
Date of Patient's Last Medical Examination
Please include dosage and frequency, as well as any herbal medicines or nutitional supplements, or N/A if it is not applicable.
Leave blank if you are unaware of any concerns.
Does the patient require antibiotics before dental treatment? *
Is the patient pregnant, trying to be pregnant, or breastfeeding? *
Fill out all that apply to the patient.
Does the patient smoke? *
If the answer is Yes, please fill out the following information:
Seizures or Epilepsy
Please fill out if applicable.
Does the patient suffer from Seizures or Epilepsy? *
Date of Last Seizure
Date of Last Seizure
Medical Conditions
Please Check All That Apply To Your Patient's Medical History *
Screening history for TMJ (Temporomandibular Disorders)
Has the patient ever been treated for temporomandiubular disorders (TMJ)? *
Does the patient have difficulty opening their mouth? *
Does the patient's jaw joints emit noise? *
Does the patient's jaw get "stuck", "locked", or "go out"? *
Does the patient have pain in or about the ears or cheeks? *
Does the patient have pain chewing, yawning, or opening their mouth wide? *
Does the patient's bite feel uncomfortable or unusual? *
Has the patient ever had an injury to their jaw, neck, or head? *
Has the patient ever had arthritis? *
Does the patient grind or clench their teeth? *
I certify the information above is complete, accurate, and correct.
I understand that medical conditions or medication can affect dental treatment, local anesthesia, and/or general anesthesia. You agree to notify this office of any change in the patient's medical condition or health status. You give consent to the dental treatment that the doctor indicates on the examination chart and any other treatment deemed necessary to the planned dental treatment. You agree and accept full responsibility for the portions not covered by your insurance company. This portion is to be paid at the time the service is provided.