Medical and Dental History Review Form Are you in good health?YesNo Are you taking any of the following medications? If so, please list. AspirinNoYes Are you allergic to or had a reaction to any of the following? If so, please list. LatexNoYes AspirinNoYes IodineNoYes Do you have or have you had a history of the following: Artificial heart valves, heart murmurNoYes Shortness of breath/COPD/respiratory problemsNoYes Frequent/persistent headacheNoYes Sinus troubleNoYes HepatitisNoYes Thyroid problemsNoYes Kidney problemsNoYes Venereal diseasesNoYes Mental health issuesNoYes CancerNoYes Current smokerNoYes Current smokeless tobacco userNoYes Current e-cig userNoYes Heart attackNoYes PacemakerNoYes DiabetesNoYes Epilepsy/SeizuresNoYes AIDS/HIVNoYes Stomach Ulcer/RefluxNoYes Low Blood Pressure/AnemiaNoYes ProstheticsNoYes Radiation TreatmentNoYes ArthritisNoYes Pregnant/BreastfeedingNoYes Taking Birth ControlNoYes Currently in PainNoYes SwellingNoYes Bleeding GumsNoYes Loose/Mobile TeethNoYes TMJ (problems opening/closing of mouth)NoYes Sensitive TeethNoYes Dry MouthNoYes Frequent Cold/Mouth SoresNoYes Injury to Teeth/FaceNoYes Teeth Break/Fracture EasilyNoYes Drink Fluoridated Water/Use FluorideNoYes Use MouthwashNoYes Like Your Smile?NoYes Like the Color of Your TeethNoYes If you use tobacco, how many packs or cans per day? How often do you brush your teeth? How often do you floss your teeth? Date of Last Dental Visit Do you require antibiotics prior to dental treatmentNoYes What is the reason for your visit?
