COAST DENTAL
PATIENT'S DENTAL HEALTH

Name______________________________ 
Account Number_________________________
Why have you come to see us today? (e.g., pain, check up, etc.)___________________________ Previous Dentist Name_________________________

Reasons for changing dentists:____________________________________ Last visit ____________________Last cleaning______________________

Have you had any problems with past dental treatment?____________________________________________________________________________

Are you nervous about seeing a dentist c Yes! c No If yes, please tell us why:____________________________________________________________

How often do you brush? ______________________________ Do you floss? c Yes c No   How often? _______________________________________
(Please circle Y for Yes and N for No) 
Y N  I clench or grind my teeth during the day or while sleeping. 
Y N  My gums bleed while brushing or flossing. 
Y N  I like my smile. 
Y N  I prefer tooth colored fillings.  
Y N  I avoid brushing part of my mouth due to pain. 		 Y N  My gums feel tender or swollen. 
Y N  I have problems eating.
Y N  I have had orthodontics. 
Y N  I have had a facial or jaw injury.
Y N  I want my teeth straighter.
Y N  I want my teeth whiter. 
What are your dental priorities?  ___________________________________________________________________________________________-___
________________________________________________________________________________________________________________________
(e.g., appearance, dental health, financial considerations, etc.)
________________________________________________________________________________________________________________________
__________________________________________________PATIENT'S MEDICAL HISTORY______________________________________________
I consider my health to be (Please check one): c Excellent c Good c Fair c Poor 
Do you have or have you had any of the following? 
Please circle Y for yes or N for no.
 1. Y N  Heart disease 
 2. Y N  Heart Murmur/Mitral Valve Prolapse 
 3. Y N  Stroke
 4. Y N  Congenital Heart Lesions 
 5. Y N  Rheumatic Fever 
 6. Y N  Abnormal Blood Pressure 
 7. Y N  Anemia
 8. Y N  Prolonged Bleeding Disorder 
 9. Y N  Tuberculosis or Lung Disease  
10. Y N Asthma  
11. Y N Hay Fever  
12. Y N Sinus Trouble  
13. Y N Epilepsy/Seizures  
14. Y N Ulcers  
15. Y N Implants/Artificial Joints:
      Hip-Knee______ Other_______________________ 
16. Y N I smoke or use Chewing Tobacco. If yes, how much per day?____
      How many years?___ 
17. Y N  I have consumed alcohol within the last 24 hours. 
18. Y N  I usually take an antibiotic prior to dental treatment.
19. Y N  Have you ever taken Fen-Phen or Redux? 
20. Y N  I have had major surgery. Year _________Type of operation ____________________________________________________________
____________________________________________________________
Year ________________Type of operation_________________________
Doctors notes only:
22. Y N  Liver Disease
23. Y N  Jaundice 
24. Y N  Hepatitis Type_______
25. Y N  Diabetes
26. Y N  Excessive Urination and/or Thirst
27. Y N  Infectious Mononucleosis ("Mono")
28. Y N  Herpes
29. Y N  Arthritis
30. Y N  Sexually Transmitted/Venereal Diseases
31. Y N  Kidney Disease
32. Y N  Tumor or Malignancy
33. Y N  Cancer/Chemotherapy
34. Y N  Radiation/Therapy
35. Y N  History of Drug Addiction
36. Y N  AIDS
37. Y N  Immune Suppressed Disorder
38. Y N  Hearing Loss
39. Y N  Fainting Spells
40. Y N  Glaucoma
41. Y N  History of Emotional Nervous Disorder
Women:
42. Y N  Are you taking birth control
43. Y N  Are you or could you be pregnant
21. Y N Do you have any other medical problem or medical history NOT listed on this form? ________________________________________________ ________________________________________________________________________________________________________________________
Are you allergic to any of the following? Please circle Y for yes and N for no
44. Y N Aspirin/ibuprofen
45. Y N Sulfa Drugs/Sulfites/Sulfides
46. Y N Penicillin 
47. Y N Codeine
48. Y N Latex, Metals, Plastics
49. Y N Local Anesthetics (Novocaine)
50. Y N Other Medications? Which ones?_____________________
Please list all medications you are currently taking:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
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In case of an emergency, please contact: 
Name_____________________________________________ Relationship____________________________ Phone_(___)_____________________
________________________________________________________________________________________________________________________
Medical Health Reviewed By: 
_____________________________________________________    _________________________________________________________________
Doctors Signature                                                      Date                     Patient/Parent or Guardian's Signature                                              Date