Newport Beach Dentist: Fill a patient form at Dr. Spath's office or submit online, Newport Beach dentist

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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.

Patient’s Name* :

Patient’s Age :

Referred by :

Internet	Website
Friend	Other

If Friend or Other, please specify

How would you rate the condition of your mouth? :

Excellent	Good
Fair	Poor

Previous dentist :

How long have you been a patient? :

Month
Years

Date of most recent dental exam :

dd
mm
yyyy

Date of most recent x-rays :

dd
mm
yyyy

Date of most recent treatment (other than a cleaning)

dd
mm
yyyy

I routinely see my dentist every :

3 mo. 4 mo.
6 mo. 12 mo.
Not routinely

What is your immediate concern? :

Name of Physician :

Specialty of the physician:

Most recent physical examination :

dd
mm
yyyy

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	26. osteoporosis/osteopenia (i.e. taking bisphosphonates)	Yes No
2. an allergic reaction to		27. arthritis	Yes No
Aspirin, Ibuprofen, Acetaminophen	Yes No	28. glaucoma	Yes No
Penicillin	Yes No	29. contact lenses	Yes No
Prythromycin	Yes No	30. head or neck injuries	Yes No
Tetracycline	Yes No	31. epilepsy, convulsions (seizures)	Yes No
Codeine	Yes No	32. neurologic problems	Yes No
Local anesthetic	Yes No	33. viral infections and cold sores	Yes No
Fluoride	Yes No	34. any lumps or swelling in the mouth	Yes No
Metals (gold, stainless steel)	Yes No	35. hives, skin rash, hay fever	Yes No
Any other medications		36. venereal disease	Yes No
		37. hepatitis (type )	Yes No
3. heart problems	Yes No	38. HIV / AIDS	Yes No
4. heart murmur	Yes No	39. tumor, abnormal growth	Yes No
5. rheumatic fever	Yes No	40. radiation therapy	Yes No
6. scarlet fever	Yes No	41. chemotherapy	Yes No
7. high blood pressure	Yes No	42. emotional problems	Yes No
8. low blood pressure	Yes No	43. psychiatric treatment	Yes No
9. a stroke	Yes No	44. antidepressant medication	Yes No
10. artificial prosthesis (i.e. heart valve or joints)	Yes No	45. alcohol / drug dependency	Yes No
11. anemia or other blood disorder	Yes No	ARE YOU:
12. prolonged bleeding due to a slight cut	Yes No	46. presently being treated for any other illness	Yes No
13. emphysema	Yes No	47. aware of a change in your general health	Yes No
14. tuberculosis	Yes No	48. taking medication for weight management (i.e. fen-phen	Yes No
15. asthma	Yes No	49. taking dietary supplements	Yes No
16. breathing or sleep problems (i.e. snoring, sinus)	Yes No	50. often exhausted or fatigued	Yes No
17. kidney disease	Yes No	51. subject to frequent headaches	Yes No
18. liver disease	Yes No	52. a smoker or smoked previously	Yes No
19. jaundice	Yes No	53. considered a touchy person	Yes No
20. thyroid or parathyroid disease	Yes No	54. often unhappy or depressed	Yes No
21. hormone deficiency	Yes No	55. FEMALE - taking birth control pills	Yes No
22. high cholesterol	Yes No	56. FEMALE - pregnant	Yes No
23. diabetes	Yes No	57. MALE - prostate disorders	Yes No
24. stomach or duodenal ulcer	Yes No
25. digestive disorders (i.e. gastric reflux)	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

PLEASE ANSWER YES OR NO TO THE FOLLOWING

PERSONAL HISTORY

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

SMILE CHARACTERISTICS

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

BITE AND JAW JOINT

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

TOOTH STRUCTURE

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

GUM AND BONE

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 :