• Dental History

  • Print blank form to fill by hand

  • When was your last dental visit?*
     - -
  • Are you experiencing any dental problems?*
  • Do you have any loose teeth?*
  • Do you have any chipped teeth?*
  • Do you have any broken teeth?*
  • Are there any spaces between your teeth where food often gets stuck?*
  • Do you frequently get headaches or migraines?*
  • Do you have any jaw joint issues (such as popping) or pain?*
  • Do you clench and/or grind your teeth when you are awake or asleep?*
  • Do your teeth feel worn down?*
  • Do you snore at night or commonly have a hard time sleeping well?*
  • Do you have any sort of sleep apnea that you are aware of?*
  • Have you ever had periodontal (gum) treatment of any kind?*
  • Do your gums bleed when you brush your teeth?*
  • Do your gums bleed when you floss?*
  • Have you ever had orthodontic treatment such as braces or aligner therapy?*
  • Are you interested in short-term braces?*
  • Do you have wisdom teeth?*
  • If so, are they bothering you?*
  • Are you interested in dental implants to replace missing teeth?*
  • What level of dental treatment are you interested in (Select one)*

  • 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?*
  • Have you ever been hospitalized or had a major operation?*
  • Have you ever had a serious head or neck injury?*
  • Are you taking any medications, pills or drugs?*
  • Do you take or have you taken, Phen-Fen or Redux?*
  • Have you ever taken Fosamax, Boriva, Actonel or any other medications containing bisphosphonates?*
  • Are you on a special diet?*
  • Do you use tobacco?*
  • Do you use controlled substances?*

  • Women: Are You

  • Pregnant/Trying to get pregnant?*
  • Taking oral contraceptives?*
  • Nursing?*

  • Are you allergic to any of the following?

  • *

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

  • Have you ever had any serious illness not listed above?*
  • Date*
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  • Should be Empty: