Dental and health questionnaire patient’s First Name Patient’s Last Name

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Patient’s First Name___________________ Patient’s Last Name_________________________________

Family Dentist___________________________________________________________________________

Frequency and type of dental care______________________________________________________________

Have you had previous periodontal care? Yes No

If yes, when and by whom?__________________________________________________________________________

Have you ever had orthodontic treatment? Yes No

Do you have or have you experienced any of the following?


Bad Taste/Breath

Bleeding Gums

Floss Snagging

Food Impaction
Recent Tooth Loss

Sensitivity to Biting Pressure

Loose Teeth

Spontaneous Tooth Movement

Do you use: Gum Coffee Soft Drinks Tea Breath Mints

Is your toothbrush: Hard Medium Soft

Does your M.D. require you to pre-medicate with antibiotics prior to all dental procedures? Yes No

If yes, why?__________________________________________________________________________

Are you allergic to any medications or drugs, Latex, Iodine? Yes No

If yes, please list_______________________________________________________________________

Have you ever had adverse reaction to any drugs, anesthetics, sedatives, narcotics,

aspirin, ibuprofen (Motrin)? Yes No

If yes, please list_______________________________________________________________________

Have there been any changes in your general health in the past year? Yes No

Have you had a serious illness, operation or hospitalization within the past five years? Yes No

If yes, please describe___________________________________________________________________
Are you taking or have you recently taken prescribed medications, inhalers, over the counter

natural or herbal preparations? Yes No

If yes, please list_______________________________________________________________________

Have you ever taken or been treated with bisphosphonates (medications to treat bone loss) of any kind? Yes No

If yes, what and how long? ______________________________________________________________

Have you ever had excessive bleeding that required special treatment? Yes No

Is there a history of Diabetes in your family? Yes No

Do you use any kind of tobacco? Yes No

If yes, how much: per day, week, month_____________________________________________________

Do you use any kind of alcohol? Yes No

If yes, how much: per day, week, month_____________________________________________________

Do you have any history of substance abuse or do you currently use recreational drugs? Yes No

Choose all of the following that you may have had in the past or that currently apply to you:


  • Chest Pain Upon Exertion

  • Shortness of Breath

  • High Blood Pressure

  • Low Blood Pressure

  • Heart Valve Prosthesis

  • Mitral Valve Prolapse

  • Congenital Heart Lesion

  • Rheumatic Fever

  • Heart Murmur

  • Damaged Heart Valve

  • Heart Arrhythmia

  • Tachycardia

  • Heart Surgery

  • Cardiac Pacemaker


  • Seizures/Epilepsy

  • Stroke

  • Migraines

  • Depression/Anxiety

  • Mental Health Problems


  • Cataracts

  • Glaucoma

  • Wear Contact Lenses

  • Severely Impaired Vision


  • Kidney Disease

  • Impaired Kidney Function

  • Hemodialysis


  • Asthma

  • Emphysema

  • Tuberculosis



  • Alcoholism

  • Anorexia or Bulimia

  • ARC

  • Arthritis

  • Blood Transfusions

  • Cancer

  • Chemotherapy

  • Chronic Fatigue

  • Cold Sores

  • Connective Tissue Disorder

  • Diabetes

  • G.I. Ulcers

  • Hepatitis

  • Impaired Liver Function

  • Irritable Bowel Syndrome

  • Jaundice

  • Joint Replacement Surgery

  • Osteoporosis

  • Persistent Cough

  • Radiation Therapy

  • Recurrent Infections

  • Recent Weight Loss

  • Sinus Trouble

  • Sleep Apnea

  • Substance Abuse

  • Systemic Lupus

Do you have any disease, problem or condition not listed above? Please explain___________________________________ ____________________________________________________________________________________________________

Are you required, due to health, to restrict your work or activity in any way? Yes No

For women check all that apply:  I am pregnant  I am nursing  I am taking birth control pills

Have you experienced an unusual reaction to any of the following?

  • Anaprox

  • Aspirin

  • Codeine

  • Erythromycin

  • Iodine

  • Latex

  • Nitrous Oxide

  • Penicillin

  • Percodan

  • Sulfa

  • Synalgos

  • Tetracycline

  • Tylenol

  • Valium

  • Vicodin

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status. Moreover, I accept the courtesy Dr. Beagle’s office offers in submitting insurance claims on my behalf. I hereby authorize the release of any information relating to said claims, and authorize as well, payment directly to Dr. Beagle’s office of the group insurance benefits, otherwise payable to me. Moreover, I understand that this filing is done as a courtesy and that I am responsible for all cost of dental treatment.

Patient Signature_________________________________________________________Date__________________________

Continued on reverse side

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