TMD Exam Health History Form

TMD Exam Health History Form 2020-06-12T16:28:54+00:00

Patient Information

1. Tell us about Yourself

How would you like to receive appointment reminders?

Emergency Contact:

2. Responsible Party Information

Primary Responsible Party

3. Referral Information

Who has referred you for this consultation?


4. Dental Benefits Information

We are pleased to work with you and your insurance carrier to obtain the maximum dental benefit for treatment



5. Dental Health History

Your answers to the following questions will be helpful in selecting the safest and most effective means of providing your care. All information will be kept strictly confidential.

Is there any unfinished care to be completed with your dentist?

Have you noticed any change in your bite or dental alignment recently?

What is your primary reason for your exam today?

6. Medical Health History

Are you currently under a physician's care?

Are you currently taking any medcations?

List any medications or supplements you are currently taking:

Are you allergic to medications?

Are you pregnant?

Please check if you have had any of the following conditions:

Heart MurmurAnemia, Blood DisordersKidney DiseaseHerpes (Fever blisters)ArthritisHeart SurgeryHypertensionTuberculosisNervous/AnxiousSkin conditionsHeart Valve DefectRheumatic FeverCancerBronchitisEndocrine DisordersHepatitisAsthmaBone DisordersProlonged BleedingDiabetesEpilepsyFainting

Do you have any allergies? (Please Identify)

Is there any other condition or problem that you think we should know about?

7. 3rd Party Authorization

I, give written consent to Dr. Reid Friesen to divulge any diagnostics, records, correspondence and/or information relating to myself to:

I consent to the collection, use and disclosure of my personal information as set out above. By typing my name below, I am electronically signing and certifying that I am in understanding of all of the above statements

Have questions for us?