Medical History Form
Edward Liu
2123 N. Aurelius Road  
Holt, Michigan.,  48842
ph: 517-699-2985
Patient Information* indicates a required field
First Name: *Last Name: *
Birth Date: (mm/dd/yyyy)    Gender: Email Address:
Address Line 1:Pref. Phone: *     
Address Line 2:Home Phone:
City:Work Phone:
Cell Phone:
Dental QuestionsMedical QuestionsAllergiesMedical Hist. (pt. 1)Medical Hist. (pt. 2)
Dental Questions
How long since you have seen a dentist?         
Date of last complete dental exam: (mm/dd/yyyy)
Date of last full mouth x-rays: (mm/dd/yyyy)
Are you having problems now?    
If Yes:
Is your present dental health good?    
Do you wear dentures?      
Are you unhappy with your dentures?    
Would you like permanent replacements?    
Are you apprehensive about dental treatment?    
Name of Previous Dentist:
Prev. Dentist City & State:
Please rank the following in the order in which they would KEEP YOU FROM having dental treatment:
(with "1" being least likely to keep you from having treatment and "5" being very likely)
Fear of Pain:               
Cost of Treatment:               
Lack of Concern:               
Missing Work Time:               
Have you had any periodontal (gum) treatments?   
Do your gums bleed or feel tender or irritated?   
Are your teeth sensitive to hot, cold, or pressure?   
Are you unhappy with the appearance of your teeth?   
Are you aware of grinding or clenching your teeth?   
Do you have headaches, ear aches, or neck pains?   
Have you worn braces on your teeth (orthodontics)?   
Do you have discolored teeth that bother you?   
Would you like your smile to look better or different?   
Do you regularly use dental floss?   
Dental QuestionsMedical QuestionsAllergiesMedical Hist. (pt. 1)Medical Hist. (pt. 2)
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