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Adult Health History Form

Your overall health as well as any medications which you take could have an important inter-relationship with the dental care you receive.
Please answer each of the following questions completely.


Patient Medical History


1. Are you under medical treatment now? YesNo

2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years? YesNo

3. Are you taking any medication(s) including non-prescription medicine? YesNo

4. Have you ever taken Fen-Phen/Redux? YesNo

5. Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates? YesNo

6. Have you taken Viagra, Revatio, Cialis or Levitra in the last 24 hours? YesNo

7. Do you use tobacco? YesNo

8. Do you use controlled substances? YesNo

9. Are you wearing contact lenses? YesNo

10. Do you have or have you had any of the following? Check all the apply
High Blood PressureHeart DiseaseChest PainsHeart AttackCardiac PacemakerEasily Winded
Rheumatic FeverHeart MurmurStrokeSwollen AnklesHay Fever/AllergiesAngina
Fainting/SeizuresFrequently TiredTuberculosisAsthmaAnemiaRadiation TherapyLow Blood Pressure
GlaucomaEmphysemaEpilepsy/ConvulsionsCancerRecent Weight LossLeukemiaArthritis
Liver DiseaseDiabetesJoint ReplacementHeart TroubleKidney DiseaseHepatitis/JaundiceRespiratory Problems
AIDS or HIV InfectionSTDMitral Valve ProlapseThyroid ProblemStomach Troubles/UlcersOther

11. Are you allergic to or have you had any reactions to the following? Check all the apply
Local Anesthetics (e.g. Novocain)IodineAspirinPenicillin or any other AntibioticsSulfa Drugs
BarbituratesAny Metals (e.g. nickel, mercury, etc.)Latex RubberSedativesOther

12. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)? YesNo

13. Are You a Woman? YesNo

13a. Are you pregnant or think you may be pregnant YesNo

13b. Are you nursing? YesNo

13c. Are you taking oral contraceptives? YesNo

Patient Dental History

1. Do your gums bleed while brushing or flossing? YesNo

2. Are your teeth sensitive to hot or cold liquids/foods? YesNo

3. Are your teeth sensitive to sweet or sour liquids/foods? YesNo

4. Do you have any sores or lumps in or near your mouth? YesNo

5. Do you feel pain to any of your teeth? YesNo

6. Have you had any head, neck or jaw injuries? YesNo

7. Do you have frequent headaches? YesNo

8. Do you clench or grind your teeth? YesNo

9. Have you ever had any orthodontic treatment? YesNo

10. Have you ever had any difficult extractions in the past? YesNo

11. Have you ever had any prolonged bleeding following extractions? YesNo

12. Have you ever received oral hygiene instructions regarding the care of your teeth and gums? YesNo

13. Do you bite your lips or cheeks frequently? YesNo

14. Do you like your smile? YesNo

15. Do you wear dentures or partials? YesNo

16. Have you ever experienced any of the following problems in your jaw? Check all the apply
ClickingPain (joint, ear, side of face)Difficulty in opening or closingDifficulty in chewing

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less that the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.


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Bedford Family & Laser Dentistry