DENTAL HEALTH HISTORY
Which location will you be visiting?
*
Please Select
Minot
Rolette
Turtle Lake
Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
When was your last dental visit?
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have:
Any bleeding disorders
Sensitive teeth
Bleeding gums
Dry mouth
Do you use any form of tobacco?
Yes
No
Are you allergic to, or have you had any reaction to:
Local anesthesia/Novocaine
Penicillin or other antibiotics
Sulfa Drugs
Any metals
Rubber/latex
Codeine
Aspirin
Ibuprofen
Other
List any previous or current cancer(s):
List any previous major surgeries:
List any previous joint replacements:
Do you have, or have you ever had any of the following? (Check all that apply)
History of heart trouble
Pacemaker
Heart surgery
Rheumatic fever
Heart valve replacement
Any other coronary event
Diabetes
Shortness of breath
Kidney disease/dialysis
TMJ/jaw joint pain
Headaches/migraine
Stroke
High blood pressure
Low blood pressure
High cholesterol
Fibromyalgia
Epilepsy/seizures
Thyroid disorders
Hepatitis A
Hepatitis B
Hepatitis C
Tuberculosis
AIDS or HIV
Liver disease
Asthma
Chemotherapy
Radiation
Other
For women - check if you are:
Pregnant
Nursing
Taking any birth control medication
Do you take a daily aspirin?
Yes
No
List all medications you are currently taking:
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