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Patient Info - Dental And Medical History Form

Please note that it is important to fill in all the fields before submitting. Thank you.


Patient’s Name* :
  *Last Name

  Middle Name

  *First Name
Prefer to be called : Age : Referred by :
Is there anything we can do to make your visit more enjoyable or comfortable?


Medical history

Name of Physician : Specialty of the physician:
Purpose of the recent physical examination :
Most recent physical examination :
What is your estimate of your general health?
DO YOU HAVE or HAVE YOU EVER HAD
01. hospitalization for illness or injury
02. an allergic reaction to
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthetic
fluoride
metals ( nickel, gold, silver, )
latex
Any other medications :
03. heart problems, or cardiac stent within the last six months
04. history of infective endocarditis
05. artificial heart valve, repaired heart defect (PFO)
06. pacemaker or implantable defibrillator
07. artificial prosthesis (heart valve or joints)
08. rheumatic or scarlet fever
09. high or low blood pressure
10. a stroke (taking blood thinners)
11. anemia or other blood disorder
12. prolonged bleeding due to a slight cut (INR > 3.5)
13. emphysema, shortness of breath, sarcoidosis
14. tuberculosis, measles, chicken pox
15. asthma
16. breathing or sleep problems (i.e. snoring, sinus)
17. kidney disease
18. liver disease
19. jaundice
20. thyroid, parathyroid disease, or calcium deficiency
21. hormone deficiency
22. high cholesterol or taking statin drugs
23. diabetes (HbA1c = )
24. stomach or duodenal ulcer
25. digestive disorders (i.e. celiac disease, gastric reflux)
26. osteoporosis/osteopenia (i.e. taking bisphosphonates)
27. arthritis, rheumatoid arthritis, lupus
28. glaucoma
29. contact lenses
30. head or neck injuries
31. epilepsy, convulsions (seizures)
32. neurologic disorders (ADD/ADHD, prion disease)
33. viral infections and cold sores
34. any lumps or swelling in the mouth
35. hives, skin rash, hay fever
36. STI / STD
37. hepatitis (type )
38. HIV / AIDS
39. tumor, abnormal growth
40. radiation therapy
41. chemotherapy, immunosuppressive
42. emotional problems
43. psychiatric treatment
44. antidepressant medication
45. alcohol / street drug use
ARE YOU:
46. presently being treated for any other illness
47. aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)
48. taking medication for weight management (i.e. fen-phen)
49. taking dietary supplements
50. often exhausted or fatigued
51. experiencing frequent headaches
52. a smoker, smoked previously or use smokeless tobacco
53. considered a touchy person
54. often unhappy or depressed
55. FEMALE - taking birth control pills
56. FEMALE - pregnant
57. MALE - prostate disorders

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)
List all medications, supplements, and or vitamins taken within the last two years
Drug Purpose Drug Purpose


Dental history

How would you rate the condition of your mouth? Previous dentist :
How long have you been a patient? Months        Years Date of most recent dental exam :
Date of most recent treatment
(other than a cleaning)
Date of most recent x-rays :
I routinely see my dentist every : 3 mo.   4 mo.   6 mo.   12 mo.   Not routinely
What is your immediate concern?

PLEASE ANSWER YES OR NO TO THE FOLLOWING

PERSONAL HISTORY
01. Are you fearful of dental treatment? How fearful,on a scale of Yes No
02. Have you had an unfavorable dental experience? Yes No
03. Have you ever had complications from past dental treatment? Yes No
04. Have you ever had trouble getting numb or had any reactions to local anesthetic? Yes No
05. Did you ever have braces, orthodontic treatment or had your bite adjusted? Yes No
06. Have you had any teeth removed Yes No
GUM AND BONE
07. Do your gums bleed or are they painful when brushing or flossing? Yes No
08. Have you ever been treated for gum disease or been told you have lost bone around your teeth? Yes No
09. Have you ever noticed an unpleasant taste or odor in your mouth? Yes No
10. Is there anyone with a history of periodontal disease in your family? Yes No
11. Have you ever experienced gum recession? Yes No
12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? Yes No
13. Have you experienced a burning sensation in your mouth? Yes No
TOOTH STRUCTURE
14. Have you had any cavities within the past 3 years? Yes No
15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? Yes No
16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? Yes No
17. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth? Yes No
18. Do you have grooves or notches on your teeth near the gum line? Yes No
19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? Yes No
20. Do you frequently get food caught between any teeth? Yes No
BITE AND JAW JOINT
21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) Yes No
22. Do you feel like your lower jaw is being pushed back when you bite your teeth together? Yes No
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? Yes No
24. Have your teeth changed in the last 5 years, become shorter, thinner or worn? Yes No
25. Are your teeth crowding or developing spaces? Yes No
26. Do you have more than one bite and squeeze to make your teeth fit together? Yes No
27. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? Yes No
28. Do you clench your teeth in the daytime or make them sore? Yes No
29. Do you have any problems with sleep or wake up with an awareness of your teeth? Yes No
30. Do you wear or have you ever worn a bite appliance? Yes No
SMILE CHARACTERISTICS
31. Is there anything about the appearance of your teeth that you would like to change? Yes No
32. Have you ever whitened (bleached) your teeth ? Yes No
33. Have you felt uncomfortable or self conscious about the appearance of your teeth ? Yes No
34. Have you been disappointed with the appearance of previous dental work ? Yes No
Signature* :
      Date :