Welcome! So that we may provide you with the best possible care, please complete both dental & medical history form. All information is completely confidential.

Dental History

What is the reason for your visit today?

If referred, what is your dentist’s name?

How frequently have you had your teeth cleaned during the past 5 years?

Less than once a year

Once a year

Twice a year

Three times a year

Four times a year

Date (Mo/Year) of last dental visit

Date (Mo/Year) of last dental cleaning

Are you presently satisfied with the condition of your mouth and teeth (check one):

Very satisfied

Satisfied

It’s O.K.

Somewhat dissatisfied

Very Dissatisfied

Are any of your teeth sensitive to?

Hot or Cold?

Yes

No

Sweets?

Yes

No

Biting or Chewing?

Yes

No

Have you experienced?

Clicking or popping of the jaw?

Yes

No

Difficulty in opening or closing the mouth?

Yes

No

Difficulty in chewing on either side of the mouth?

Yes

No

Aches or pains in your jaw joints, ears, face, neck or head?

Yes

No

Have you ever had?

Orthodontic treatment?

Yes

No

Orthodontic treatment

With braces

With removable appliances When did you go through orthodontic care?

Periodontal treatment?

Scaling/Root Planing

When did you go through Periodontal care?

Scaling/Root Planing

Periodontal treatment?

Scaling/Root Planing

When did you go through Periodontal care?

Scaling/Root Planing

Oral Surgery?

Yes

No

A bite plate or mouth guard?

Yes

No

A serious injury to the mouth or head?

Yes

No

If YES, please describe:

Are you concerned about the appearance of your teeth?

Yes

No

Do your gums ever bleed or hurt?

Yes

No

If YES, when?

Do you have a problem with bad breath?

Yes

No

Are you concerned about gum recession around any of your teeth?

Yes

No

Do you frequently get cold sores, blisters, or any other lesions?

Yes

No

Do you feel nervous about having dental treatment?

Yes

No

If YES, please describe

Is there anything else about having dental treatment that you would like us to know?

Yes

No

If YES, please describe:

Health History

Physician’s Name

Address

City

Phone

Your Age

Height

Weight

Mo/Year of your last medical exam

How would you describe your present health (choose one):

Excellent

Good

Fair

Poor

Don’t Know

Has there been any change in your general heath in the past year?

Yes

No

Have you had a serious illness, operation or hospitalization during the past 5 years? If YES, please describe:

Yes

No

Has your M.D. told you to take antibiotics prior to having any type of dental Procedure?

Yes

No

Have you ever taken orally: Aredia, Zometa, Fosamax, Actonel or any other Bisphosphonates?

Yes

No

Have you ever taken Pondimin (Fendluramine), Phen-Fen (Phentermine), or Redux For weight reduction?

Yes

No

Have you ever had excessive bleeding that required special treatment?

Yes

No

Are you required, due to health, to restrict your work or activity in any way?

Yes

No

Do you use any kind of tobacco?

Yes

No

If YES, how much?

Do you use any kind of Alcohol?

Yes

No

If YES, how much?

Do you have any history of substance abuse or do you currently use recreational Drugs?

Yes

No

Check all of the following that you may have had in the past or that currently apply to you:

Do you have any disease, problem or condition not listed above? If YES,please explain:

Have you lost or gained more than 10 pounds in the past year?

Yes

No

For Women, check all that are appropriate:

I am pregnant

I am nursing

I am taking birth control pills

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 provider or agency, who may release such information to you. I will notify the doctor of any changes in my health or medication.

Patient Signature

Date