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Ramsin k. Davoud DDS. Family & Cosmetic Dentistry
Print blank form to fill by hand

  Last name

  Mid name

  First name
Birthday :

Dental History

1. When was your last dental visit?
2. Where and who was your last dentist?
3. Approximately how often were your appointments with your last dentist?
4. Are you experiencing any dental problems? (Please explain):
5. How often do you: Brush your teeth?
Water Jet Floss?
6. Do you have any: Loose Teeth? Yes No
Chipped Teeth? Yes No
Broken Teeth? Yes No
7. Are there any spaces between your teeth where food often gets stuck? Yes No
8. Do you frequently get headaches or migraines? Yes No
9. Do you have any jaw joint issues (such as popping) or pain? Yes No
10. Do you clench and/or grind your teeth when you are awake or asleep? Yes No
11. Do your teeth feel worn down? Yes No
12. Do you snore at night or commonly have a hard time sleeping well? Yes No
13. Do you have any sort of sleep apnea that you are aware of? Yes No
14. Have you ever had periodontal (gum) treatment of any kind? Yes No
15. Do your gums bleed when you brush your teeth? Yes No
Do your gums bleed when you floss? Yes No
16. Have you ever had orthodontic treatment such as braces or aligner therapy? Yes No
17. Are you interested in short-term braces? Yes No
18. Do you have wisdom teeth? Yes No If so, are they bothering you? Yes No
19. Are you interested in dental implants to replace missing teeth? Yes No
20. What level of dental treatment are you interested in (circle one): Emergency Long-term
21. How do you feel about your smile? What (if any) improvements would you like to see?
22. What are your goals with our office?

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Medical History

Are you under a physician's care now? Yes No
If Yes, Please Explain:
Have you ever been hospitalized or had a major operation? Yes No
If Yes, Please Explain:
Have you ever had a serious head or neck injury? Yes No
If Yes, Please Explain:
Are you taking any medications, pills or drugs? Yes No
If Yes, Please Explain:
Do you take or have you taken, Phen-Fen or Redux? Yes No
If Yes, Please Explain:
Have you ever taken Fosamax, Boriva, Actonel or any other medications containing bisphosphonates? Yes No
If Yes, Please Explain:
Are you on a special diet? Yes No
Do you use tobacco? Yes No
Do you use controlled substances? Yes No
Women: Are You -
Pregnant/Trying to get pregnant? Yes No
Taking oral contraceptives? Yes No
Nursing? Yes No
Local Anesthetics
Sulfa Drugs
If Other, Please Explain:
AIDS/HIV Positive
Aizheimer's Disease
Artificial Heart Valve
Artificial Joint
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Cortisone Medicine
Drug Addiction
Easily Winded
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Hepatitis A
Hepatitis B or C
High Blood Pressure
High Cholesterol
Hives or Rash
Irregulare Heartbeat
Kidney Problems
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Scarlet Fever
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Swelling of Limbs
Thyroid Disease
Tumors or Growths
Venereal Disease
Yellow Jaundice
Have you ever had any serious illness not listed above? Yes No
If Yes, Please List:


* To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

(Your digital signature (full name) is as legally binding as a physical signature.)