291 N. 300 E., Ste. B,
American Fork, UT 84003

801-756-0933 / 801-756-2346

WELCOME to Brite Family Dental

Health Questionnaire

Date:
Patient's Name:
Phone:
E‐mail:
Date of Birth
Physician's Name, Telephone Number:

DENTAL

What type of dental treatment do you feel you need?
Is there anything about your smile that you would like to change?
Are you nervous about having dental treatment?
Are you in pain or discomfort at this time?
When did you last see a dentist?
Who was your previous dentist?
Have you ever had a severe reaction to dental treatment or local anesthetics?

Please check (√) any of the following that apply to you:


MEDICAL

Please check (√) any of the following that you have had in the past or have at present:


Please check (√) any of the following to which you are allergic (i.e., itching, rash, swelling of hands/feet/eyes/tongue) or which make you sick:

Have you been under the care of a physician or in the hospital within the past two years?
If Yes, for what conditions?
Do you take any medications or drugs (prescribed or over the counter) including aspirin, birth control or supplements?
If Yes, please specify name and purpose of medication:
Do you require antibiotic pre-medication for a heart condition, artificial valve or artificial joint?
Have you ever had any excessive bleeding requiring special treatment?
Do you smoke or chew tobacco?
If Yes, are you interested in quitting?
Have you ever taken, or are you currently taking drugs without a prescription?
When you walk up stairs or exert yourself, do you ever have to stop due to pain in your chest, shortness of breath, or because you are very tired?
Do your ankles swell during the day?
Do you snore or have difficulty breathing while sleeping?
If Yes, have you sought any treatment?

For Women:
Are you pregnant or suspect you may be pregnant?
If Yes, what is your due date?
Do you use oral contraceptives?
Are you nursing?
Have you ever taken Fosamax, Boniva, or any other drug prescribed to decrease bone resorption or any drugs for metastatic bone cancer?
If you have any disease, condition, or concern not mentioned, please list:


To the best of my knowledge, all of the preceding answers are accurate. If I ever have a change in my medical condition or in my medications, I will inform the doctor and his associates at the next appointment without fail. I understand the importance that such changes can affect my dental treatment and I assume the responsibility to notify the doctor and his associates.

Patient, legal guardian or authorized agent of patient:

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Date:

MEDICAL HISTORY UPDATES

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