Dental Medical History | Enamel Dental Centre

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Personal Information

Name*

Prefix First Middle Last

Preferred Name

First

Sex*

Male

Female

Date of Birth*

DD slash MM slash YYYY

Phone*

Email*

Primary Care Physician's Name*

Dr.

How did you hear about us?*

What method would you prefer we use to contact you?*

Phone - Home

Phone - Cell

Text

Other

Have you ever had a serious illness or are you under the care of a physician now?*

Yes

Please Explain*

When was your last medical examination?*

DD slash MM slash YYYY

Have you ever had complications following dental treatment?*

Yes

Please Explain*

Has any member of your family had diabetes?*

Yes

Have you ever had any injury, surgery or x-ray therapy to your face or jaws?*

Yes

Please Explain*

Do you currently or have you ever used tobacco?*

Yes

Please Explain*

Smoking or chewing, frequency, etc

Please indicate if any of the following apply to you

Allergy - Aspirin*

Yes

Allergy - Latex*

Yes

Allergy - Codiene*

Yes

Allergy - Erythromycin*

Yes

Allergy - Iodine*

Yes

Allergy - Penicillin*

Yes

Allergy - Sulpha*

Yes

Allergy - Local Anesthetic*

Yes

Anemia*

Yes

Arthritis*

Yes

Artificial Joints*

Yes

Asthma*

Yes

Blood Disease*

Yes

Cancer*

Yes

Contraceptive Use*

Yes

Diabetes*

Yes

Dizziness/Fainting*

Yes

Emphysema*

Yes

Epilepsy*

Yes

Excessive Bleeding*

Yes

Excessive Bruising*

Yes

Gastro-Intestinal*

Yes

Glaucoma*

Yes

Hard to Freeze*

Yes

Hay Fever*

Yes

High Blood Pressure*

Yes

Head Injury*

Yes

Hearing Disabled*

Yes

Heart Disease*

Yes

Heart Murmur*

Yes

Hepatitis A*

Yes

Hepatitis B*

Yes

Hepatitis C*

Yes

HIV + AIDs*

Yes

Hives*

Yes

Jaundice*

Yes

Kidney Disease*

Yes

Liver Disease*

Yes

Low Blood Pressure*

Yes

Mental Disorders*

Yes

Multiple Sclerosis*

Yes

Nervous Disorders*

Yes

Pacemaker*

Yes

Pre-Medication*

Yes

Pregnancy*

Yes

Radiation Treatment*

Yes

Respiratory Problems*

Yes

Rheuamtism*

Yes

Rheumatic Fever*

Yes

Rheumatoid Arthritis*

Yes

Sinus Problems*

Yes

Skin Rash*

Yes

STD*

Yes

Stomach Problems*

Yes

Stroke*

Yes

Thyroid Disease*

Yes

TMD*

Yes

Tuberculosis*

Yes

Tumors*

Yes

Ulcers*

Yes

Wheelchair*

Yes

Do you have any other conditions, diseases, allergies or health concerns that we should be aware of that are not listed above?

Please list

What is the reason for your dental visit?*

Approximately when was your last dental cleaning?*

Are your experiencing any dental pain?

Areas of hot or cold sensitivity, pressure sensitivity?

How do you feel about the appearance of your smile?

Interested in whitening or changing the shape of your teeth?

How do you rate your anxiety level in the dental chair? (Scale of 1-10) Interested in relaxation dentistry? What's made you anxious in the past?

Do you experience any TMD symptoms including headaches, ringing in the ears, abnormal opening, clenching or grinding, clicking/popping or jaw pain?

If yes please explain

Have you ever been in a major accident. If yes, when and what happened?

I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) third-party insurance carriers, payors, and/or healthcare practitioners.

I understand that I am financially responsible for services provided.

To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health, I will inform the office at my next dental appointment.*

I agree to the above terms

Signature

Name*

First Last

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Medical and Dental History

Personal Information

Please indicate if any of the following apply to you