Dental and Health History Form Quinn Dental Health and History If you are human, leave this field blank. Patient Name * Today's Date * Birth Date * Dental History Reason for Today's Visit Date of Last Dental Care Former Dentist Date of last dental x-rays Address Check if you have trouble with any of the following * None of these Bad breath Bleeding gums Clicking or popping jaw Food collection between teeth Sore/growths in your mouth Grinding teeth Loose teeth Periodontal treatment Broken fillings Previous orthodontics (braces) Sensitivity to hot Sensitivity to sweets Sensitivity to biting Sensitivity to cold How often do you brush? How often do you floss? Have you been taught how to control dental plaque? Special devices used Medical History Physician's Name Date of Last Visit Have you had any serious illnesses or operations? Yes No If yes please describe Check if you have or have had any of the following * None of these Anemia Arthritis Artificial heart valve Artificial joints Asthma Bleeding disorder Cancer Chemical dependency Chemotherapy Cortisone treatments Cough Diabetes Epilepsy Headaches Heart Murmur Heart problems Hemophilia Hepatitis High blood pressure HIV/AIDS Jaw pain Kidney disease Mitral Valve Prolapse Pacemaker Pregnant Radiation Rheumatic Fever Shortness of breath Sinus problems Skin condition Stomach problems Stroke Thyroid problem Tobacco use Ulcer Other Medications List medications currently taking Pharmacy Name Pharmacy Phone Allergies Please check if you are allergic to any of the following: * Aspirin Codeine Novacaine Penicilin Sulfa Latex None of these Any other allergies? (What?) I understand all of the above information is necessary to provide me with dental care in a safe and efficient manner. To the best of my knowledge, the above information is complete and correct. I also understand that it is my responsibility to inform the staff of any changes in my or my minor child's health. Patient, Parent, or Personal Representative Name: * Date * reCAPTCHA By filling out your name and the date above and clicking submit you are giving us permission to have all the information on this form.