Patient Medical History

Perfect Smile - Portland & Falmouth Maine General and Cosmetic Dentist

Please take the time to fill out this form online to save you time when you come in for your appointment. Or fill out this printable version and bring it in with you on the day of your appointment.

Patient's Full Name: *

Date of Birth:

Sex:

Have you ever had to pre-medicate for a dental procedure?

Check the conditions that apply to you:

Diabetes - Type:

Mitral Valve Prolapse

Heart Murmur

Artificial Joint (joint replacement, pins, rods)

Cardiovascular Disease (heart attack, angina, coronary insufficiency, coronary occlusion, or other)
Other Cardiovascular Disease:

Anemia / Blood disease

Asthma

Blood Pressure / High

Blood Pressure / Low

Cancer - Type:

Chemotherapy

Congenital Heart Lesions

Cough up Blood

Epilepsy / Seizures

Chemical Dependency

Hemophilia / Bleeding Disorder

Fainting / Nervousness

Heart Trouble

Jaw Pain

Pacemaker

Hepatitis

Herpes Virus (cold sores)

HIV Positive / AIDS

Rheumatic Fever

Mental Health

Migraine Headaches

Neck / Head Pain

Radiation Therapy

Scarlet Fever

Transplant

Tuberculosis

Respiratory Disease

TMJ / Clicking Joint

Sinus

Tobacco Habit

Tonsillitis

Ulcer

Women

Are you taking birth control pills?

Describe (Dates if applicable):

Are you pregnant?

Describe (Dates if applicable):

Are you nursing?

Describe (Dates if applicable):

Are you taking blood thinners?

Describe (Dates if applicable):

Have you ever had a blood tranfusion?

Describe (Dates if applicable):

Have you ever had any serious illnesses or operations?

Describe (Dates if applicable):

List any medications you are currently taking:

List any food or drug allergies you have:

Current Physician Information

Are you being treated by a physician?

If yes, please explain:

My primary medical physician is:

Physician's Phone:

Dental History

Reason for today's visit:

Date of last dental care:

Date of last dental x-rays:

Former Dentist:

Former Dentist's Address:

Former Dentist's Phone:

Check if you have had problems with any of the following:

Bad Breath

Bleeding Gums

Clicking / Popping of Jaw

Food Collection Between Teeth

Grinding Teeth

Loose Teeth

Broken Fillings

Periodontal Treatment

Sensitivity to Hot/Cold

Sensitivity to Sweets

Sensitivity When Biting

Sores or Growths in your Mouth

How often do you brush?:

How often do you floss?:

Happy with the appearance of your teeth?

Do you want whiter teeth?

Ever had an unpleasant dental experience?

Authority to Treat

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or minor child, ever have a change in health.

I give Dr. Robert V. Nelson the authority to administer dental x-rays, local injections, anesthetics and, if requested, nitrous oxide in the subsequent treatment of my case. If I have a medical condition such as a heart murmur that requires premedication, I acknowledge that it is my responsibility to inform and remind the doctor, assistant or hygienist at the beginning of each visit.

The Doctor is not responsible for completion of treatment if I consistently fail to keep scheduled appointments.

I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist or any other member of his staff responsible for any errors or omissions that I may have made in the completion of this form.

I accept the conditions mentioned above. *

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