Patient Medical History

Patient Name:


Office Phone:   Date of Last Exam:

Are you under a medical treatment now? Yes No

Have you ever been hospitalized for any surgical operation or serious illness? Yes No

Are you taking any medications? Yes No
** If yes, please complete the medication list form on the next page. **

Have you ever taken Fen-Phen/Redux? Yes No

Do you use tobacco? Yes No

Do you use alcohol, cocaine, or other drugs? Yes No

Are you allergic to, or have you ever had a reaction to, any of the following:
  Local Anesthetics like Novocaine   Penicillin or other antibiotics
  Sulfa drugs   Barbiturates, sedatives or sleeping pills   Aspirin
  Iodine   Any metals (nickel, mercury, etc.)   Latex or rubber
  Other  - Please List:

Women are you:
  Pregnant/Trying to get pregnant: Yes No
  Nursing: Yes No
  Taking birth control pills: Yes No

Do you have, or have you had, any of the following?

Have you ever had any serious illness not listed above? Yes No
If yes, please explain:


Patient Dental History - Please check all that apply:

Would you like fresher breath?
Would you like whiter teeth?
Do your gums ever bleed?
Are your teeth sensitive to hot or cold liquids or foods?
Are your teeth sensitive to sweet or sour liquids or foods?
Do you feel pain in any of your teeth?
Do you have any sores or lumps in or near your mouth?
Have you had any head, neck or jaw injuries?

Have you ever experienced any of the following problems in your jaw?
   Pain (joint, ear, side of face)
   Difficulty opening or closing
   Difficulty chewing

Do you have frequent headaches?
Do you clench or grind your teeth?
Do you bite your lips or cheeks frequently?
Have you ever had any difficult extractions in the past?
Have you ever had any orthodontic work?
Have you ever had prolonged bleeding following an extraction?

Payment is due at the time of service.
My method of payment will be: Cash/Check   Credit Card   Dental Financing   Dental Insurance

I certify that I am covered by insurance company and I assign directly to Gowasack Family Dentistry all insurance benefits, otherwise payable to me. I understand I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform the necessary dental services I may need.

Signature:      Date:

Our office is HIPAA compliant and is committed to meeting or exceeding the standards of Infection Control mandated by OSHA, the CDC, and the ADA.