drmowdds.com - Dental History

Patient Name:

Birth Date:

Date

1. Do you feel very nervous about having dental treatment?

YesNo

2. Have you had any serious trouble associated with any previous dental treatment?

YesNo

If yes, explain

3. Have you been satisfied with your previous care?

YesNo

If not, please explain

4. Would you prefer a local anesthetic for most dental treatment?

YesNo

5. Are you troubled with bad breath?

YesNo

6. Are you self-conscious about the appearance of your teeth?

YesNo

If yes, explain

7. How long has it been since your last thorough dental examination?

8. When were your teeth last cleaned?

When were your teeth last X-rayed?

9. How often do you brush your teeth?

How often do you floss?

10. What, if anything, would you do to change the appearance of your teeth?

11. Are you taking any of the following?

	Yes	No
Antibiotics or sulfa drugs
Anticoagulants (blood thinners)
Medicine for high blood pressure
Cortisone or steroids (Prednisone, etc.)
Tranquilizers (Valium, etc.)
Aspirin or anti-inflammatory agent
Dilantin or other anti-convulsant
Insulin, Tolbutamide, Orinase or similar drug
Digitalis or drugs for heart trouble
Nitroglycerin
Narcotic Analgesic (Codeine, etc.)

Any other medicine

12. Are you allergic to or have you ever reacted adversely to any of the following?

	Yes	No
Latex (rubber)
Local anesthetics (Novocaine, Lidocaine, etc.)
Penicillin or other antibiotics
Nitrous Oxide
Sulfa Drugs
Aspirin or anti-inflammatory drugs
Barbiturates, sedatives, or sleeping pills
Narcotic analgesics (codeine, etc.)
Metals or jewelry

Any other?

13. Have you ever been treated for any gum diseases (gingivitis, periodontitis, trenchmouth)?

YesNo

14. Do your gums bleed or feel tender or irritated when you brush your teeth?

YesNo

15. Do you grind or clench your teeth?

YesNo

16. Have you had frequent sores or swellings of your mouth, jaws or lips?

YesNo

17. Have you had any injuries to your mouth or jaw?

YesNo

If yes, explain

18. Are your teeth sensitive to hot, cold, sweets, biting?

YesNo

19. Are there areas of your mouth where food sticks or gets caught?

YesNo

20. Do you have pain in the region of your ears?

YesNo

21. Do your jaws often feel tired or sore?

YesNo

22. Do you experience jaw joint clicking, popping, grating when you open or close your mouth or problem not listed?

YesNo

23. Do you have frequent headaches and/or pain in the neck, shoulders or back?

YesNo

24. Do you have any disease, condition or problem not listed?

YesNo

If yes, explain

Previous Dentist’s Name

Your Physician’s Name

Phone Number

Please enter a valid phone number.

To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication.

Patient’s Signature

Date

DENTAL HISTORY