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?

If yes, do we need to prescribe?

Check the conditions that apply to you:
Diabetes Mitral Valve Prolapse Heart Murmur Artificial Joint (joint replacement, pins, rods) Cardiovascular Disease (heart attack, angina, coronary insufficiency, coronary occusion) Anemia/Blood Disease Asthma Blood Pressure/High Blood Pressure/Low Cancer 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

If you have diabetes, indicate what type

If you have a Cardiovascular Disease, please indicate what type:

If you have Cancer, please indicate what type:

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 transfusion?

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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