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Dental and Medical History Form

Please note that it is important to fill in all the fields before submitting. Thank you.
*Last Name :
Middle Name : *First Name :
Age : Referred by : Internet Website Friend Other
How would you rate the condition of your mouth? Excellent Good Fair Poor
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 Months 4 Months 6 Months 12 Months Not Routinely
What is your immediate concern?
Name of Physician : Specialty of the physician:
Most recent physical examination :
Purpose of the recent physical examination :
What is your estimate of your general health? Excellent Good Fair Poor
Do you Have or Have you ever Had?
1. hospitalization for illness or injury Yes No
2. An allergic reaction to :
Aspirin, Ibuprofen, Acetaminophen Yes No
Penicillin Yes No
Erythromycin Yes No
Tetracycline Yes No
Codeine Yes No
Local anesthetic Yes No
Fluoride Yes No
Metals (gold, stainless steel) Yes No
Any other medications :
3. heart problems Yes No
4. heart murmur Yes No
5. rheumatic fever Yes No
6. scarlet fever Yes No
7. high blood pressure Yes No
8. low blood pressure Yes No
9. a stroke Yes No
10. artificial prosthesis (i.e. heart valve or joints) Yes No
11. anemia or other blood disorder Yes No
12. prolonged bleeding due to a slight cut Yes No
13. emphysema Yes No
14. tuberculosis Yes No
15. asthma Yes No
16. breathing or sleep problems (i.e. snoring, sinus) Yes No
17. kidney disease Yes No
18. liver disease Yes No
19. jaundice Yes No
20. thyroid or parathyroid disease Yes No
21. hormone deficiency Yes No
22. high cholesterol Yes No
23. diabetes Yes No
24. stomach or duodenal ulcer Yes No
25. digestive disorders (i.e. gastric reflux) Yes No
26. osteoporosis/osteopenia (i.e. taking bisphosphonates) Yes No
27. arthritis Yes No
28. glaucoma Yes No
29. contact lenses Yes No
30. head or neck injuries Yes No
31. epilepsy, convulsions (seizures) Yes No
32. neurologic problems Yes No
33. viral infections and cold sores Yes No
34. any lumps or swelling in the mouth Yes No
35. hives, skin rash, hay fever Yes No
36. venereal disease Yes No
37. hepatitis ( type ) Yes No
38. HIV / AIDS Yes No
39. tumor, abnormal growth Yes No
40. radiation therapy Yes No
41. chemotherapy Yes No
42. emotional problems Yes No
43. psychiatric treatment Yes No
44. antidepressant medication Yes No
45. alcohol / drug dependency Yes No
46. presently being treated for any other illness Yes No
47. aware of a change in your general health Yes No
48. taking medication for weight management (i.e. fen-phen) Yes No
49. taking dietary supplements Yes No
50. often exhausted or fatigued Yes No
51. subject to frequent headaches Yes No
52. a smoker or smoked previously Yes No
53. considered a touchy person Yes No
54. often unhappy or depressed Yes No
55. FEMALE - taking birth control pills Yes No
56. FEMALE - pregnant Yes No
57. MALE - prostate disorders Yes No
Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment :
List all medications, supplements, and or vitamins taken within the last two years
Drug Purpose Drug Purpose
1. 5.
2. 6.
3. 7.
4. 8.
Please answer Yes or No to the following :
Are you fearful of dental treatment? Yes No
Have you had an unfavorable dental experience? Yes No
Have you ever had complications from past dental treatment? Yes No
Have you ever had trouble getting numb or reactions to local anesthetic? Yes No
Did you ever have braces, orthodontic treatment or had your bite adjusted? Yes No
Have you had any teeth removed Yes No
Is there anything about the appearance of your teeth that you would like to change ? Yes No
Have you ever whitened (bleached) your teeth ? Yes No
Are you self conscious about your teeth ? Yes No
Have you been disappointed with the appearance of previous dental work ? Yes No
Do you / would you have any problems chewing gum Yes No
Do you / would you have any problems chewing bagels or other hard foods Yes No
Have your teeth changed in the last 5 years, become shorter, thinner or worn Yes No
Are your teeth crowding or developing spaces Yes No
Do you have more than one bite or do you clench (squeeze) to make your teeth fit together Yes No
Do you have any problems with sleep or wake up with an awareness of your teeth? Yes No
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) Yes No
Do you have tension headaches or sore teeth Yes No
Do you wear or have you ever worn a bite appliance Yes No
Have you had any cavities within the past 3 years Yes No
Do you have a dry mouth Yes No
Are any teeth sensitive to hot, cold, biting or sweets Yes No
Have you ever had a toothache, cracked filling, broken, chipped or cracked tooth Yes No
Do you avoid brushing any part of your mouth Yes No
Do you feel or notice any holes (i.e. pitting) in your teeth Yes No
Have you ever been diagnosed or treated for periodontal (gum) disease Yes No
Have you ever experienced gum recession Yes No
Is there anyone with a history of periodontal disease in your family Yes No
Do your gums bleed when brushing, flossing or eating Yes No
Are your teeth becoming loose Yes No
Have you ever noticed an unpleasant taste or odor in your mouth Yes No
Have you experienced a burning sensation in your mouth Yes No
*Signature :
Date :