HEALTH HISTORY FORM

Date:

Name:

Home Phone:

Cell:

Work:

Email:

Street Address:

City:

State:

Zip Code:

Mailing Address (if different than above):

Street Address:

City:

State:

Zip Code:

Date of Birth:

Sex:

M F

Occupation:

Preferred Pharmacy:

Emergency Contact Name:

Phone Number:

Relationship:

If you are completing this form for another person, what is your relationship to this person?

Signature of Responsible party:

DENTAL INFORMATION

Do your gums bleed when you brush?

Yes No Unknown

Have you ever had orthodontic treatment?

Yes No Unknown

Are your teeth sensitive to cold, hot, sweets, or pressure?

Yes No Unknown

Do you have headaches, earaches or neck pains?

Yes No Unknown

Have you had any periodontal (gum) treatments?

Yes No Unknown

Do you wear removable/fixed dental appliances?

Yes No Unknown

Have you been told you have periodontal (gum) disease?

Yes No Unknown

Are you aware of loose teeth or broken fillings?

Yes No Unknown

Are your gums swollen or tender?

Yes No Unknown

Are you a mouth breather?

Yes No Unknown

Have you had any problems associated with previous dental treatment or past dental experiences?

Yes No Unknown

If so explain:

Do you frequently get blisters on lips or mouth?

Yes No Unknown

Do you have a family history of periodontal disease?

Yes No Unknown

Do you ever get a burning sensation on tongue?

Yes No Unknown

Do you chew on one side of mouth?

Yes No Unknown

Do you get clicking or popping of your jaw?

Yes No Unknown

Do you bite your nails or foreign objects?

Yes No Unknown

Do you get jaw pain or tiredness?

Yes No Unknown

Does food collect between your teeth?

Yes No Unknown

Do you have pain when brushing?

Yes No Unknown

Do you or have you been told you grind your teeth?

Yes No Unknown

Oral habits

Tongue/lip piercing

Ice chewing

Musical instrument with mouthpiece

Using teeth as a tool

What fluoride products do you use/consume?

Toothpaste

Water

Rinses

Other

If Other, please specify:

What are the three most important factors you desire from your dental office?

How do you feel about the appearance of your teeth?

Do you have any problems with bad breath?

How often do you floss?

How often do you brush?

How often do you have dental check ups?

Please indicate the level of dental care you would like us to provide:

Emergency care as needed

Consultation to solve a specific problem

Routine exam and preventive care

Comprehensive care, optimal dental health and appearance

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