shenlingdds.com - Medical History Form

DENTAL HISTORY
Patient Name
Patient Account No.
Medical Alert
Welcome! So that we may provide you with the best possible care please complete both sides of this medical/dental history form. All information is completely confidential.
What is the reason for your visit today?
Date of Last Dental Visit

MonthDayYear
Date
Last Dental Cleaning

MonthDayYear
Date
Last Full Mouth X-rays

MonthDayYear
Date
What was done at your last dental visit?
Previous Dentist's Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
Please enter a valid phone number.
How often do you have dental examinations?
How often do you brush your teeth?
How often do you floss?
Have you ever used or are currently using topical fluoride?

YesNo
What other dental aids do you use? (Interplak, toothpick, etc.)
Do you have any dental problems now?

YesNo
If yes, please describe:

Are any of your teeth sensitive to:

	Yes	No
Hot or cold?
Sweets?
Biting or Chewing?
Have you noticed any mouth odors or bad tastes?
Do you frequently get cold sores, blisters or any other oral lesions?
Do your gums bleed or hurt?
Have your parents experienced gum disease or tooth loss?
Have you noticed any loose teeth or change in your bite?

Do you:

	Yes	No
Clench or grind your teeth while awake or asleep?
Bite your lips or cheeks regularly?
Hold foreign objects with your teeth? (pencils, pipe, pins, nails, fingernails)
Mouth breathe while awake or asleep?
Have tired jaws, especially in the morning?
Snore or have any other sleeping disorders?
Smoke/chew tobacco or use other tobacco products?

Have you ever had

	Yes	No
Orthodontic treatment?
Oral Surgery?
Periodontal treatment?
Your teeth ground or the bite adjusted?
A bite plate or mouth guard?

Have you experienced:

	Yes	No
Clicking or popping of the jaw?
Pain? (joint, ear, side of face)
Difficulty in opening or closing the mouth?
Difficulty in chewing on either side of the mouth?
Headaches, neckaches or shoulder aches?
Sore muscles (neck, shoulders)?

Are you satisfied with your teeth's appearance?

YesNo
Would you like to keep all of your teeth all of your life?

YesNo
Do you feel nervous about having dental treatment?

YesNo
If so, what is your biggest concern?
Have you ever had an upsetting dental experience?

YesNo
If yes, please describe
Have you ever been told to take a pre-medication prior to dental treatment?

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

YesNo
If yes, please describe

	Yes	No
Heart (Surgery, Disease, Attack)
Chest Pain
Congenital Heart Disease
Heart Murmur
High/Low Blood Pressure
Mitral Valve Prolapse
Artificial Heart Valve/Pacemaker
Rheumatic Fever
Arthritis/Rheumatism
Cortisone Medicine
Swollen Ankles
Stroke
Diet (Special/Restricted)
Artificial Joints (hip, knee, etc.)
Kidney Trouble
Ulcers Diabetes
Thyroid Problems
Glaucoma
Contact lenses
Emphysema
Chronic Cough
Tuberculosis
Asthma
Hay Fever/Allergy/Hives
Latex Sensitivity
Sinus Trouble
Radiation Therapy
Chemotherapy
Tumors
Hepatitis A
Hepatitis B
Hepatitis C
Venereal Disease
A.I.D.S./H.I.V. Positive
Cold Sores/Fever Blisters
Blood Transfusion
Hemophilia
Sickle Cell Disease
Bruise Easily
Liver Disease/Yellow Jaundice
Neurological Disorders
Epilepsy or Seizures
Fainting or Dizzy Spells
Nervous/Anxious
Psychiatric/Psychological Care

DENTAL HISTORY