Health History Questionnaire

Medical History: Home do you rate your physical health?

Good

Fair

Poor

Are you taking medication(s) including non-prescription medicine?

Yes

No

Have you ever taken prescription medications for weight loss (diet pills)? If so, did you take any of the following:

No

Fen-Phne

Pondimen

Rednx

Other

Don't remember

Do you have any of the following?

High blood pressure

Heart attack

Rheurnatic Fever

Heart Disease

Pacemaker

Heart murmur

Mitral Valve Prolapse

Joint replacement or implant

Respiratory problems

Diabetes

Epilepsy/Convulsions

Hemophilia, abnormal bleeding

AIDS or HIV

Leukemia

Cancer

Hepatitis/Jaundice

Tuberculosis

Hay fever/Allergies

Thyroid problems

Other

None of the above

Are you allergic to any of the following:

Local anesthetics (e.g. Novocain)

Penicillin or another other antibiotics

Aspirin

Codeine

Sulfa drugs

Any metals (e.g. nickel, mercury, etc.)

Latex rubber

Other

None of the above

Do you smoke or use tabacco? If yes, please use comments to specify how many packs per day.

Yes

No

Women only! Are you pregnant or think you might be pregnant?

No

Yes, I'm pregnant

Dental History: What is the main purpose of your visit today?

Checkup

Tooth ache

Teeth or gums hurting or bothering me

Other

When was the last time you were seen by a dentist for a complete dental examination or teeth cleaning? Do you have any of the following?

Gums bleed while brushing or flossing

Food tend to become caught in between teeth

Clench or grind teeth

Have tired jaws, especially in the morning

Feel pain in some teeth

Any other dental problems

None of the above

Is there anything else about having dental treatment that you would like us to know?

Yes

No

I hereby acknowledge that my answers are accurate and to the best of my knowledge. I authorize Perfect Smile Dental Care to take X-rays, photographs deemed appropriate, and to make a thorough diagnosis of my dental needs.

I Agree

I Disagree