Dental & Medical History

DENTAL HISTORY

Patient's Name

Patient Account No.

Medical Alert

What is the reason for your visit today?

Last Full Mouth X-rays

Last Dental Cleaning

Date of Last Dental Visit

What was done at your last dental visit?

Previous Dentist's Name

Address

City

State

Zip

Telephone No.

How often do you have dental examinations?

How often do you brush your teeth?

How often do you floss?

What other dental aids do you use? (lnterplak, toothpick, etc.)

If yes, please describe

Are any of your teeth sensitive to:

Hot or cold?

Sweets?

Biting or Chewing?

Have you noticed any mouth odors or bad tastes?

Do you frequently get cold sores, blisters or any other oral lesions?

Do your gums bleed or hurt?

Have your parents experienced gum disease?

Have you noticed any loose teeth or change in your bite?

If yes, Where?

Do you:

Clench or grind your teeth while awake or asleep?

Bite your lips or cheeks regularly?

Hold foreign objects with your teeth? (pencils, pipe, pins, nails, fingernails)

Mouth breathe while awake or asleep?

Have tired jaws, especially in the morning?

Snore or have any other sleeping disorders?

Smoke/chew tobacco or use other tobacco products?

Have you ever had:

Orthodontic treatment?

Oral Surgery?

Periodontal treatment?

Your teeth ground or the bite adjusted?

A bite plate or mouth guard?

lf so, please describe, including cause

Have you experienced:

Clicking or popping of the jaw?

Pain? (joint, ear, side of face)

Difficulty in opening or closing the mouth?

Difficulty in chewing on either side of the mouth?

Headaches, neckaches or shoulder aches?

Sore muscles (neck, shoulders)?

Have you noticed any loose teeth or change in your bite?

Are you satisfied with your teeth's appearance?

Would you like to keep all of your teeth all of your life?

lf so, what is your biggest concern?

lf yes, please describe

MEDICAL HISTORY

Patient's Name

Patient Account No.

Medical Alert

Physician's Name

Phone No.

Please describe

If yes, Please list name and dosage

If yes, did you take any of the following?

Fen-Phen

Pondimen

Redux

Other

If yes, Please specify

If yes, please list

Months?

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.

By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Guardian / Signature

Date

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