Or. George Er Or. Grucella Health History Form Date _ Chart Number _

DMaie D FemaleName-------------~f------M~ Last First M.1.

Dental History Date of Birth _

Reason for today's visit _

Date of last dental visit _ Former Dentist _

Place a check mark on "yes" or "no" to indicate if you have had any of the following:

Have you had any serious trouble with previous dental treatment? DYes D ~lo

If so explain:

.Bad breath I

DYes DN;o Loose teeth or broken fillings DYes DNa . - - .L

Bleeding gums DYes DNo . Mouth breathing DYes DNa .... ­ _

Blisters on lips or mouth 'DYes DNo Mouth pain, brushing DYes DNa

Chew on side of mouth DYes DNa Orthodontic treatment DYes DNo

Cigarette, pipe, or cigar smoking DYes DNo - _. Pain around ear l

- DYes DNo

Clicking or popping jaw DYes DNo Periodontal treatment DYes DNo -

Dry mouth DYes DNo -Sensitivity to cold 'L .'..." " ___ .'

DYes DNo

Food collection between the teeth DYes DNo - --­ ,~

SensitiVity to heat .-

DYes DNa

Grinding teeth DYes DNa Sensitivity when biting .. DYes DNo -

Gums swollen or tender DYes DNa - Sores or growths in your mouth DYes DNa .

Jaw pain or .tiredness DYes DNo ... . How often do you brush? __

Lip or cheek biting DYes DNo How often do you floss?

Medications List any medications you are currently taking (If you have a list please present it to the front desk to be photocopied):

Are you taking or have you ever taken/been treated with a Bisphosphonate (Fosamax)? DYes D No

Pharmacy Name _ Phone _

Allergies D Aspirin D Barbiturates (Sleeping pills) D Codeine D Iodine D Latex D Local Anesthetic

D Penicillin D Sulfa D Other _

Women Are you pregnant? DYes D No Due Date _ Are you nursing? DYes D~lo

Taking Birth Control pills? DYes D No

~ho may we contact in case of an ernergency? ~

Relationship _ Phone _

Health History Physician's Name _ Date of last visit _

Physician's office address _ Phone _

Place a check mark on "yes" or "no" to indicate if you have had any of the following:

AIDS/HIV __ _ -'- _--,- _-_ -0 Yes -. -.-0 No _ _ History of Organ Transplant 0 Yes ONa

Anemia 0 Yes 0 No Jaundice 0 Yes 0 No Arthritis, Rheumatism -':-'-~'~ ..~.~ .. - DYes : 0 No Jaw Pain -. - ~ .. - - 0 Yes 0 No ­

Artificial Heart Valves --- .. -. - - 0 Yes [] No Kidney Disease .- _.- - 0 Yes 0 No

Artificial Joints ..._.:~~ _~ ~__~D Yes - -0No Liver Disease _ ...=~_ -_ 0 Yes 0 No

Asthma 0 Yes 0 No Low Blood Pressure 0 Yes 0 No

Back Problems Dves 0 No _ _ MitralValve Prolapse _ _ 0 Yes 0 No

Bleeding abnormally w/extractions or surgery 0 Yes 0 No Nervous Problems 0 Yes 0 No

Blood Disease '_-~. --0 Yes -0 NQ • - ~ Pacemaker __~~ _-_-= 0 Yes 0 No

Cancer 0 Yes 0 No Psychiatric Care 0 Yes 0 No

Chemical Dependen~y ~==~_=O Yes 0 No ~ _ Radiation Treatment ~. .-. 0 Yes 0 No

Chemotherapy 0 Yes 0 No Respiratory Disease 0 Yes 0 No

Circulatory Problems ~_. ~~_ D YeSONo Rheumatic Fever _ _ _ DYes 0 I~o Congenital Heart Lesions 0 Yes 0 ~Io Scarlet Fever 0 Yes 0 No

Cortisone Treatments -.-~ ~-=- 'D Yes 0 No Shortness of Breath -_~-~--:- oYes 0 No

Cough, Persistent or Bloody 0 Yes 0 No Sinus Trouble 0 Yes 0 I~o

Diabetes _._ __ __ ---=-_~ DYes ONo Skin RaSh _~__~~= _~ 0 Yes ONo

Emphysema 0 Yes 0 No Special Diet 0 Yes 0 No

Do you wear contact lenses? _ ' Dve's-- DNa ~ ~ STD "_ 0 Yes 0 l~o Epilepsy 0 Yes 0 No Stroke 0 Yes 0 No Fainting or Dizziness ---:- _-- - -- 0 Yes --0 No ~ ~ Swollen Feet or Ankles -_.- 0 Yes 0 No

Glaucoma 0 Yes 0 No Thyroid Problems 0 Yes 0 No Headaches .- --~ -_~~-~ .__- ~D Yes - ONo _ . Tonsillitis ~~_-~ -. 0 Yes ONo

Heart Murmur 0 Yes 0 No Tuberculosis 0 Yes 0 No

Heart Problems - - ~.-- - -. OVesO No Tumor or Growth on Head or Neck 0 Yes D No

Hepatitis Type Ulcer 0 Yes 0 No High Blood Pressure ~"-. ·------~-·D Yes :0 No Weight Loss, Unexplaine.d - i DYes 0 No

Do you wear a full upper denture /partial? 0 Yes 0 No How old? _

Do you wear a full lower denture/partial? 0 Yes 0 No How old? _

How many years total have you worn dentures/partials? _

Are you happy with the fit of your denture/partial? 0 Yes 0 No

Are you happy with the appearance of your denture/partial? 0 Yes 0 No

Consent I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I consent to the dentist's use and disclosure of my records (or my child's records) to carry out treatment, to obtain payment, and for those activities and

health care operations that are related to treatment or payment. I attest to the accuracy of the information on this page.

Patient's or Guardian's Signature _ Oate _

Doctor's Signature. _ Oate _