Medical History Form

Patient Information

Full Name

If Child, Parent's Name

Phone Number

E-Mail Address

Physician Name

Date of Last Physical

Reason for Visit

Are You Currently Under a Physician's Care?

Yes No

Have You Ever Been Hospitalized?

Yes No

Date of Last Dental Visit

Date of Last Dental X-Ray

If Wearing Dentures, Age of Dentures

Ever Had Novocaine or Other Local Anesthetic?

Yes No

Are You Taking or Have Taken Steroid or Cortisone Therapy?

Yes No

Are You Taking or Have Taken Any Oral Bisphosphonates?

Yes No

Are You Taking or Have Taken Any IV Bisphosphonates (Aredia, Zometa, Bonefos)?

Yes No

Have You Taken Antibiotics Prior to Dental Procedures in the Past?

Yes No

Are You a Smoker?

Yes No

If So, How Much Do You Smoke? Or, How Long Ago Did You Quit?

Are You Pregnant?

Yes No

If Pregnant, Your Estimated Delivery Date?

Are You Currently Nursing?

Yes No

Please List All Medications You Are Allergic To

Have You Had an Adverse Reaction or Become Ill to Penicillin, Aspirin, Codeine, Local Anesthetics, Latex, Metals, or Any Other Medication or Substance?

Yes No

Please List All Medications You Are Currently Taking

Do You Currently Take Fish Oil, Vitamin E, Omega 3, Plavix, Coumadin, Xarelto, or Aspirin Daily?

Yes No

Consume More Than One Alcohol Based Drink Daily?

Yes No

Do You Have Any Of The Following Problems With Your Mouth or Teeth? (Check All That Apply)

Swollen Gums

Bleeding Gums

Gums Burn or Feel Raw

Tooth Sensitive to Cold

Tooth Sensitive to Hot

Dry Mouth

Bad Taste

Teeth Feel Loose

Bite Feels Funny

Areas Trapping Food

Mouth Ulcers

Jaw Joints Click or Pop

Medical Information

Services Requested

Bodnar Periodontics provides the following services, what are you interested in?

Dental Implants

Crown Lengthening

Cosmetic Gum Lifts

Treatment of Recession

Treatment of Periodontal Disease

Gentle and Thorough Teeth Cleaning

Extractions Prior to Implants

Aesthetic Soft Tissue Grafts

Gummy Smile Reduction

Laser Assisted Therapy

Frenectomy

Biopsy

Please make sure to read our Dental Insurance Facts.

Patient Information

Medical Information

Services Requested