HEALTH HISTORY

Patient Name:

DENTAL HISTORY

Welcome! So that we may provIde you wIth the best possIble core. Please fill this Information form. All information Is completely confidential.

How did you hear obout our office?

What is the reason for your visit today?

Whom may we thank for referring you?

Date of Last Dental Visit:

Last Dental Cleaning:

Last Full Mouth X-rays:

What was done at your last dental visit?

Previous Dentist's Name:

Address:

City:

State:

Zip:

Telephone:

Why did you leave your last dentist?

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? (Interplak, toothpick, etc,)

Do you have any dental problems now?

Yes No

If yes, please describe:

Are any of your teeth sensitive to:

Hot or cold?

Yes No

Sweets?

Yes No

Biting or Chewing?

Yes No

Have you noticed any mouth odors or bad tastes?

Yes No

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

Yes No

Do your gums bleed or hurt?

Yes No

Have your parents experienced gum disease or tooth loss?

Yes No

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

Yes No

Does food tend to become caught in between your teeth?

Yes No

If yes, where?

Have you ever had:

Orthodontic treatment?

Yes No

Oral surgery?

Yes No

Periodontal treatment?

Yes No

Your teeth ground or the bite adjusted?

Yes No

A serious Injury to the mouth or head?

Yes No

If so, please describe, including cause

A bite plate or mouth guard?

Yes No

Have you experienced:

Clicking or popping of the jaw?

Yes No

Pain? (joint, ear, side of face)

Yes No

Difficulty in opening or closing the mouth?

Yes No

Difficulty in chewing on either side of the mouth?

Yes No

Headaches, neck aches or shoulder aches?

Yes No

Sore muscles (neck, shoulders)?

Yes No

Do you:

Clench or grind your teeth while awake or asleep?

Yes No

Bite your lips or cheeks regularly?

Yes No

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

Yes No

Mouth breath while awake or asleep?

Yes No

Have tired jaws, especially in the morning?

Yes No

Smoke/chew tobacco?

Yes No

Do you feel nervous about having dental treatment?

Yes No

If so, what is your biggest concern?

If there was a simple, inexpensive way to whiten your teeth, would you be interested?

Yes No

Please explain:

Are you satisfied with your teeth's appearance?

Yes No

If not what would you change?

Is there anything else about having dental treatment that you would like us to know?

Yes No

If yes, please describe:

MEDICAL HISTORY

Patient Name:

Date:

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.

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:

Are you on a special diet?

Yes No

If yes, please explain:

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

Are you allergic to any of the following?

Please check all that applies.

Aspirin

Penicillin

Codeine

Acrylic

Metal

Latex

Local Anesthetics

Other

If Other, please explain:

Do you have, or have you had, any of the following?

AIDS/HIV Positive

Yes No

Alzheimer's Disease

Yes No

Anaphylaxis

Yes No

Anemia

Yes No

Angina

Yes No

Arthritis/Gout

Yes No

Artificial Heart Valve

Yes No

Artificial Joint

Yes No

Asthma

Yes No

Blood Disease

Yes No

Blood Transfusion

Yes No

Breathing Problem

Yes No

Bruise Easily

Yes No

Cancer

Yes No

Chemotherapy

Yes No

Chest Pains

Yes No

Cold Sores/Fever Blisters

Yes No

Congenital Heart Disorder

Yes No

Convulsions

Yes No

Cortisone Medicine

Yes No

Diabetes

Yes No

Drug Addiction

Yes No

Easily Winded

Yes No

Emphysema

Yes No

Epilepsy or Seizures

Yes No

Excessive Bleeding

Yes No

Excessive Thirst

Yes No

Fainting Spells/Dizziness

Yes No

Frequent Cough

Yes No

Frequent Diarrhea

Yes No

Frequent Headaches

Yes No

Genital Herpes

Yes No

Glaucoma

Yes No

Hay Fever

Yes No

Heart Attack/Failure

Yes No

Heart Murmur

Yes No

Heart Pace Maker

Yes No

Heart Trouble/Disease

Yes No

Hemophilia

Yes No

Hepatitis A

Yes No

Hepatitis B or C

Yes No

Herpes

Yes No

High Blood Pressure

Yes No

Hives or Rash

Yes No

Hypoglycemia

Yes No

Irregular Heartbeat

Yes No

Kidney Problems

Yes No

Leukemia

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Lung Disease

Yes No

Mitral Valve Prolapse

Yes No

Osteoporosis

Yes No

Pain in Jaw Joints

Yes No

Parathyroid Disease

Yes No

Psychiatric Care

Yes No

Radiation Treatment

Yes No

Recent Weight Loss

Yes No

Renal Dialysis

Yes No

Rheumatic Fever

Yes No

Rheumatism

Yes No

Scarlet Fever

Yes No

Shingles

Yes No

Sickle Cell Disease

Yes No

Sinus Trouble

Yes No

Spina Bifida

Yes No

Stomach/Intestinal Disease

Yes No

Stroke

Yes No

Swelling of Limbs

Yes No

Thyroid Disease

Yes No

Tonsillitis

Yes No

Tuberculosis

Yes No

Tumors or Growths

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Yellow Jaundice

Yes No

Have you ever had any serious illness not listed above

Yes No

If yes, please explain:

Comments:

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.

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

SIGNATURE OF PATIENT, PARENT, or GUARDIAN:

Date field

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