Liberty Hill - Medical & Dental History Form

Medical and Dental History
Patient Name

First NameLast Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Sex
Primary Care Information
Primary Care Physician (First, Last Name & Specialty, OR Practice Name)
Date of Most Recent Physical Exam

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Purpose of Most Recent Physical Exam
What is the condition of your health?
Medical History Questions

Please fill in the info or check the appropriate box where applicable.
In the last 12-24 months, have you been hospitalized for illness or injury?
If yes, please explain.
Have you had an allergic reaction to any of the following?
If yes, please indicate reaction:

Do you have or have you ever had any of the following conditions, diseases or illnesses?

Rows	Yes	No
Heart Problems
Heart Murmur
Rheumatic fever
Scarlet fever
High blood pressure
Low blood pressure
A stroke
Artificial Prosthesis (i.e. A heart valve, joints)
Anemia or other blood disorder
Prolonged bleeding due to a slight cut
Emphysema
Tuberculosis
Asthma
Breathing/sleeping habits (i.e. Snoring, sinus)
Used CPAP or appliance
Often exhausted or fatigued
Kidney Disease
Liver Disease
Jaundice
Thyroid or parathyroid disease
Hormone deficiency
High cholesterol
Diabetes
Stomach or duodenal ulcer
Digestive disorders (gastric reflux)
Osteoporosis/osteopenia (taking bisphosphonates)
Arthritis
Glaucoma
Contact lenses
Head or neck injuries
Epilepsy/convulsions (seizures)
Neurological problems
Viral infections and cold sores
Any lumps or swelling in the mouth
Hives, skin rash, hay fever
Venereal disease
Hepatitis
HIV / AIDS
Tumor, abnormal growth
Radiation therapy
Chemotherapy
Emotional problems
Often unhappy or depressed
Psychiatric treatment
Antidepressant medication
Alcohol / drug dependency

Are you currently:

Rows	Yes	No
Being treated for any other illness?
Aware of change in your general health?
Taking meds for weight management?
Taking dietary supplements?
Subject to frequent headaches?
A smoker or smoked previously?

Are you taking birth control?
Are you pregnant?
Are you suffering from a prostate disorder?
If you answered yes to any of the above questions, please explain.
List all CURRENT medications, supplements and vitamins you are taking. After your final entry, you must click "save and add row" to finish. If you are NOT taking any medications, please type "none" and then click "save and add row".
Patient Signature
Date of Signature:
Dental History

Please fill in all information possible and check yes or no in the appropriate sections.
How would you rate the condition of your mouth?
Previous Dental Care
Name of Previous Dentist (First, Last OR Name of Office)
How long were you a patient there?
Date of Most Recent Dental Exam

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of Most Recent X-Rays

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I routinely see my dentist every (select one):
What is your immediate concern?

Personal Dental History

Rows	Yes	No
Have you had an unfavorable dental experience?
Have you ever had complications from past dental treatment?
Have you ever had trouble getting numb or reactions to local anesthetic?
Did you ever have braces, orthodontic treatment or had your bite adjusted?
Have you had any teeth removed?

Are you fearful of dental treatment?
If you answered yes to question #1 above, please indicate the level of fear you have of dental treatment.

Personal Smile Characteristics

Rows	Yes	No
Is there anything about the appearance of your teeth that you would like to change?
Have you ever whitened (bleached) your teeth?
Are you self conscious about your teeth?
Have you been disappointed with the appearance of previous dental work?

Your Bite and Jaw Joint

Rows	Yes	No
Do you / would you have any problems chewing gum?
Do you / would you have any problems chewing bagels or other hard foods?
Have your teeth changed in the last 5 years, become shorter, thinner or worn?
Have your teeth become crowded or developed spaces?
Do you have more than one bite or do you clench (squeeze) to make your teeth fit together?
Do you have any problems with sleep or waking up with awareness of your teeth?
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
Do you have tension headaches or sore teeth?
Do you wear or have you ever worn a bite appliance?

Your Tooth Structure

Rows	Yes	No
Have you had any cavities within the past 3 years?
Do you have dry mouth?
Are any teeth sensitive to hot, cold, biting or sweets?
Have you ever had toothache, cracked filling, broken, chipped or cracked teeth?
Do you avoid brushing any part of your mouth?

Your Gum and Bone

Rows	Yes	No
Have you ever been diagnosed or treated for periodontal (gum) disease?
Have you ever experienced gum recession?
Is there anyone with a history of periodontal disease in your family?
Do your gums bleed when brushing, flossing or eating?
Are your teeth becoming loose?
Have you ever noticed an unpleasant taste or odor in your mouth?
Have you experienced a burning sensation in your mouth?

Medical and Dental History