DENTAL HISTORY

Patient Name
Medical Alert
Reason for your visit?
Date of Last Dental Visit
Last Dental Cleaning
Last Full Mouth X-Rays
Previous Dentists Name
Street Address 
City 
State
Zip
Home Phone (w/ area code)
Email
How often do you have dental examinations?
How often do you brush your teeth?
What other dental aids do you use?
(Inerplak, toothpick, etc)
Do you have any dental problems now?
If yes, please describe

 
Are any of your teeth sensitive to:
Hot or Cold
Sweets
Biting or Chewing
Have you noticed any mouth odors or bad tastes?
Do you frequently get cold sores, blisters or any other oral lesions?
Do your gums bleed or hurt?
Have your parents experienced gum disease or tooth loss?
Have you noticed any loose teeth or a change in your bite?
Do you have any difficulty in chewing on either side of the mouth?
Does food tend to become caught in between your teeth?
If yes, where?
   
Do you:  
Clench or grind your teeth while awake or asleep?
Sweets
Bite your lips or cheeks regularly?
Hold foreign objects with your teeth? (pencils, pipe pins, nails, fingernails)
Mouth breathe while awake or asleep?
Have tired jaws, especially in the morning?
Smoke/chew tobacco?
How much?
   
Have you ever had:  
Orthodontic treatment?
Oral surgery?
Periodontal treatment? (gum treatment)
Your teeth ground or the bite adjusted?
A bite plate or mouth guard?
A serious injury to the mouth or head?
If yes, please describe, including cause.
   
Have you ever experienced:  
Clicking or popping of the jaw?
Pain? (joint, ear, side of face)
Periodontal treatment? (gum treatment)
Difficulty in opening or closing the mouth?
Sore muscles (neck, shoulders)?
Are you satisfied with the appearance of your teeth?
Would you like to keep all of your teeth all of your life?
Do you feel nervous about having dental treatment?

If yes, what is your biggest concern?
Have you ever had an upsetting dental experience?
If yes, please describe:
   
Have you been under the care of a medical doctor during the past two years?
If yes, for what?
Physicians Name
Street Address 
City 
State
Zip
Have you taken any medication in the past two years?
Are you taking any medication, pills or drugs now?
If yes, please list name and doses:
Are you aware of having an allergic (or adverse reaction) to any medication or substance?
If yes, please list:
Have you been a patient in the hospital during the past Five years?
 

Indicate which of the following you have had or have at present.

Heart Failure
Yes  No		 Heart Disease or Attack
Yes  No		 Angina Pectoris
Yes  No		 Congenital Heart Disease
Yes  No
Heart Murmur
Yes  No		 High Blood Pressure
Yes  No		 Arteriosclerosis
Yes  No		 Mitral Valve Prolapse
Yes  No
Artificial Heart Valve
Yes  No		 Heart Pacemaker
Yes  No		 Heart Surgery
Yes  No		 Rheumatic Fever
Yes  No
Arthritis
Yes  No		 Rheumatism
Yes  No		 Pain in Jaw Joints
Yes  No		 Cortisone Medicine
Yes  No
Drug Addiction
Yes  No		 Stroke
Yes  No		 Artificial Joints
(hips, knee, etc)
Yes  No		 Kidney Trouble
Yes  No
Ulcers
Yes  No		 Diabetes
Yes  No		 Thyroid Problems
Yes  No		 Glaucoma
Yes  No
Cosmetic Surgery
Yes  No		 Emphysema
Yes  No		 Chronic Cough
Yes  No		 Tuberculosis
Yes  No
Asthma
Yes  No		 Hay Fever
Yes  No		 Allergies or Hives
Yes  No		 Sinus Trouble
Yes  No
Radiation Trouble
Yes  No		 Chemotherapy
Yes  No		 Hepatitis A (Infectious)
Yes  No		 Hepatitis B (serum)
Yes  No
Venereal Disease
Yes  No		 A.I.D.S.
Yes  No		 H.I.V. Positive
Yes  No		 Cold Sores/Fever Blisters
Yes  No
Blood Transfusion
Yes  No		 Hemophilia
Yes  No		 Anemia
Yes  No		 Sickle Cell Disease
Yes  No
Bruise Easily
Yes  No		 Liver Disease
Yes  No		 Yellow Jaundice
Yes  No		 Epilepsy or Seizures
Yes  No
Fainting or Dizzy Spells
Yes  No		 Nervousness
Yes  No		 Psychiatric Treatments
Yes  No

Do you use more than two pillows to sleep?..................................................................................................Yes  No
Have you lost or gained more than 10 pounds in the past year?......................................................................Yes  No
Do you snore?......................................................................Yes  No
Have you ever had a sleep study?...................................................................... Yes  No
Have you ever used a CPAP device or been told you should?...................................................................... Yes  No
Do you have or have you had any disease, condition, or problem not listed?...................................................Yes  No
 If Yes, please list:
FOR WOMEN ONLY:
  Are you pregnant? Yes, what month? No
  Are you nursing? Yes  No
  Are you taking birth control pills? Yes  No
 
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provide or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.

By checking the following box, you agree to the above terms

Patients Full Name:
 

This information is NOT shared with anyone outside this office. This material is strictly confidential and collected solely for the
use of this office to process for your medical/dental records chart.  This data will be stored in your dental record. This information
will not be shared with anyone without a written consent that is signed and dated only by you.

(WARNING: there is no encryption used for protecting the confidentiality of this information that is being sent with this form submission)

 



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