New Patient Dental and Medical Questionnaire
Complete for each patient
Full Name
*
First Name
Last Name
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Physician
First Name
Last Name
Physician Phone Number
-
Area Code
Phone Number
Dental History
When was your last dental visit?
When did you last have dental x-rays?
How often do you brush your teeth?
2 or more times per day
1 per day
Infequently
Other
How often do you floss your teeth?
2 or more times per day
1 per day
Infequently
Other
Have you been seeing a dentist regularly?
No
Yes
Other
Is there something about your smile (teeth) you would like to change?
Are you being treated by a dental specialist?
No
Yes
If yes, enter dental specialist and reasons
Do any of your teeth ache?
No
Yes
If Yes, please describe.
Do you have any pain when you chew?
No
Yes
If Yes, please describe pain and location.
Do your gums bleed when you brush?
No
Yes
If yes, please describe.
Do you feel you have bad breath?
No
Yes
Have you ever been advised to take antibiotics before dental appointments?
No
Yes
If Yes, please list all medications and reason why.
Have you ever been in a vehicle accident or experienced any blows to your jaw?
No
Yes
Have you ever had any implant surgery in one or both of your jaws or jaw joints. If so who performed the surgery and when was it done?
Are you nervous during dental treatment?
Yes
No
Is there anything else not mentioned above regarding your past dental history. If so please list.
Medical History
Are you being treated for any medical condition at the present or have you been treated within the past year?
*
Yes
No
If yes, what is the medical condition?
When was your last medical Checkup?
Has there been any change in your general health in the past year? If so, please explain.
Are you taking any medications, non-prescription drugs or health supplements of any kind? If yes, please list, Medications, Dosage, and Reason. A written list from your pharmacy is very helpful.
Do you have any medication allergies or other allergies?
*
Yes
No
Not Sure
If yes, please list all allergies and severity..
Do you have or have you ever had asthma?
Yes
No
If you have asthma, list asthma triggers, date of last hospitalization (if ever), and anything else you feel we should know.
Do you have or have you ever had any heart or blood pressure problems?
Yes
No
If yes, please provide details.
Do you have or have you ever had an artificial heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (ie. congenital heart disease) or a heart transplant?
Yes
No
Please detail your condition and past treatement.
Do you have a prosthetic or artifical joint?
Yes
No
If yes, please provide details
Do you have conditions or therapies that could affect your immune system e.g. leukemia, AIDS, HIV infection, radiotherapy, chemotherapy?
Yes
No
If Yes, please provide details.
Have you ever had hepatitis, jaundice or liver disease?
Yes
No
If Yes, please provide details.
Do you have a bleeding problem or bleeding disorder?
Yes
No
If yes, have you ever been cautioned by physician? Is there something else we should be aware of?
Have you ever been hospitalized for any illnesses or operations?
Yes
No
If yes, please explain.
Do you have or have you ever had any of the following conditions:
rheumatic fever
heart murmur
pacemaker
lung disease
tuberulosis
cancer
steroid therapy
diabetes
stomach ulcers
arthritis
seizures
kidney disease
thyroid disease
drug/alcohol dependency
osteoporosis medication
Other
Are there any disease or medical problems that run in your family? (e.g. diabetes, cancer or heart disease)
Do you smoke or chew tobacco products?
Yes
No
Have you ever had a peculiar or adverse reaction to any medications or injections? If yes, please explain.
For women only: Are you breast-feeding or pregnant? If pregnant, what is the expected delivery date?
To the best of my knowledge, the above information is correct. (Signature of patient or parent/guardian)
Submit
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