1. Have you been under a physician’s care during the last two years?.................................................
If yes, who is your doctor?:____________________________________________________________
2. Are you taking any medications? (perscription or over the counter drugs).......................................
If yes, please list:____________________________________________________________________
3. Are you allergic to any drugs?....................................................................................................
If yes, please list:____________________________________________________________________
4. H4. Have you ever bled excessively after an injury or tooth extraction?.................................................
5. Do you ever have pain in your chest upon exertion?......................................................................
6. Are you ever short of breath after mild exertion?..........................................................................
7. Has there been any change in your general health in the last year?.................................................
8. Have you had unexplained weight loss, night sweats, or chronic cough?..........................................
9. Do 9. Do your ankles swell?...............................................................................................................
10. Do you have any nasal obstructions?.........................................................................................
11. Have you had dental x-rays in the last year?............................................................................
12. Have you ever had an injury to your face or jaw?........................................................................
13. Have you ever fainted in the dental office?.................................................................................
14. Do 14. Do you use tobacco in any form?..............................................................................................
If yes, check all that apply: Chew:____ Dip:____ Cigarettes:____ Cigars:____ Pipe:_____
15. Have you ever had surgery for a tumor or growth on your mouth, face, or neck?............................
16. W OMEN: Are you pregnant now? (please answer “yes” if you are unsure)........................
Are you taking birth control pills?:...................................................
Do you anticipate becoming pregnant?:................................................
Are you past menopause?:.........................................................
DENTAL HISTORY
1. Do you have pain in or near your ears?.................................................................................
2. Do you have any unhealed injuries or inflamed areas in, or around your mouth?.........................
3. Have you experienced any growth or sore spots in your mouth?...............................................
4. Have you ever had Novocaine anesthetic?.............................................................................
5. Any reactions or allergic symptoms from Novocaine?..............................................................
6. A6. Any difficult extractions in the past?.....................................................................................
7. Any prolonged bleeding following extractions in the past?........................................................
8. Do you at the present time have any dental complaints?.........................................................
If yes, please summerize:__________________________________________________________
9. Do you clench your teeth during the night or day?..................................................................
10. When was your last full mouth X-Ray taken?:_____________________ Where?:____________
11. Is a11. Is any part of your mouth sore to pressures to irritants? (cold, sweets, etc.)............................
Yes No
Yes No
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Yes No
YYes No
Yes No
Yes No
Yes No
Yes No
Yes No
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YYes No
Yes No
Yes No
Yes No
Yes No
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YYes No
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YYes No
Yes No
Today’s Date:_________________
Name:_____________________________________________________________________________________
Date of Birth:____________________________________ Soc. Sec. #:_________________________________
Email Address: __________________________________ Telephone #:________________________________
Address:___________________________________________________________________________________
City:____________________________________________ State:_____________ ZIP:____________________
GuardianGuardian’s Name (If under 18):_____________________________ Guardian Phone #: ____________________
MEDICAL HISTORY
Apple Dental
726 E. Lamar Alexander Pkwy
Maryville, TN 37904
(865) 604-6227
