Dental Office | Sequim, WA | Sequim Advanced Dental

680 W Washington St. Suite E102, Sequim, WA 98382

drscottbrooksby@gmail.com

Sequim Advanced Dental, Dr. Brooksby

Sequim Advanced Dental, Dr. Brooksby

CALL US: 360-207-2133

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Medical and Dental History Form

Medical and Dental History

Name:

Date:

Why are you here?

History of Complaint

DENTAL HISTORY

DENTAL HISTORY

City:

State:

Time Held:

Business Phone:

Spouse SS#:

Name of nearest relative:

Phone:

City/State:

Previous Dentist:

Last visit:

Phone#:

Dental Insurance Co.:

Responsible Part:

Policy #:

Medical History ~ Select all that apply

Pain or Discomfort

Stroke

Drug Addiction

Heart Disease

Bad dental experience

Special Diet

Epilepsy Seizures

Anemia

Physician care w/in 2 years

Allergic to jewelry

Fainting or dizziness

Kidney Trouble

Psychiatric Treatment

Liver Problems

Bruises easily

S

Allergy medication / drugs

Arthritis

New option

Birth Control Pills

Radiation Treatment

Chemotherapy

Hepatitis

Cold sores

Shortness of breath

Osteoporosis

Pain in jaw joints

Skin or bone grafts

Ankle swell during day

HIV/AIDS

Thyroid problems

Currently pregnant

High blood pressure

Consume alcohol

Gained or lost 10 pounds this year

Taken medication or drugs within 2 years

Excessive bleeding requiring special treatment

I certify that the above is true

I certify that the above is true

Date:

Age of first dental visit?

What was done?

Braces at what age?

Age of first extraction?

Why extracted?

How often do you go to the dentist?

When were last x-rays taken?

New Field:

Last cleaning?

New Field:

When?

How many crowns?

When did you get them?

How many bridges?

When did you get them?

How many partials?

When did you get them?

How many root canals?

When did you get them?

What was done during your 20's?

30's

40's

50's

60's

70's

80's

Do you clench your teeth?

When?

Why?

Do you get headaches?

When?

Why?

When did they start?

Do you get neck aches?

When?

Why?

When did they start?

How do you care for your teeth?

What would you like us to be able to do for you?

MEDICAL HISTORY

MEDICAL HISTORY

Prescription medications, and condition treated by the medication?

Over the counter medications and supplements?

Drug allergies

Hospitalizations~approximate year and purpose

Other medical conditions currently being treated

Significant other medical conditions you have had

History of Accidents

Psychiatric Counseling

Problems with back aches?

Hands?

Shoulders?

Legs?

Feet?

Lungs?

Heart?

Stomach?

Hearing?

Eyes?

Do you have numbness anywhere?

Have we missed anything?

How were you referred to us?

Thank you for contacting us.
We will get back to you as soon as possible.

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CONTACT INFORMATION

680 W Washington St. Suite E102, Sequim, WA 98382

360-207-2133

drscottbrooksby@gmail.com

BUSINESS HOURS

Call For An Appointment

Visa Payment Accepted

MasterCard Payment Accepted

Discover Payment Accepted

American Express Payment Accepted

Content, including images, displayed on this website is protected by copyright laws. Downloading, republication, retransmission or reproduction of content on this website is strictly prohibited. Terms of Use | Privacy Policy

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