MEDICAL HISTORY
Patient Name
*
Nickname
Age
*
Name of Physician/and their specialty
*
Most recent physical examination
*
Purpose
*
What is your estimate of your general health?
*
Excellent
Good
Fair
Poor
DO YOU HAVE or HAVE YOU EVER HAD:
Hospitalization for illness or injury
*
Yes
No
An allergic or bad reaction to any of the following:
*
aspirin, ibuprofen, acetaminophen, codeine
penicillin
erythromycin
tetracycline
sulfa
local anesthetic
fluoride
chlorhexidine (CHX)
lodine
metals (nickel, gold, silver)
latex
nuts
fruit
milk
red dye
Other
Heart problems, or cardiac stent within the last six months
*
Yes
No
History of infective endocarditis
*
Yes
No
Artificial heart valve, repaired heart defect (PFO)
*
Yes
No
Pacemaker or implantable defibrillator
*
Yes
No
Orthopedic or soft tissue implant (e.g joint replacement, breast implant)
*
Yes
No
Heart murmur, rheumatic or scarlet fever
*
Yes
No
High or low blood pressure
*
Yes
No
A stroke (taking blood thinners)
*
Yes
No
Anemia or other blood disorder
*
Yes
No
Prolonged bleeding due to a slight cut (or INR >3.5)
*
Yes
No
Pneumonia, emphysema, shortness of breath, sarcoidosis
*
Yes
No
Chronic ear infections, tuberculosis, measles, chicken pox
*
Yes
No
Breathing problems (e.g. asthma, stuffy nose, sinus congestion)
*
Yes
No
Sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)
*
Yes
No
Kidney disease
*
Yes
No
Liver disease or jaundice
*
Yes
No
Vertigo (e.g. "the room is spinning")
*
Yes
No
Thyroid, parathyroid disease, or calcium deficiency
*
Yes
No
Hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome)
*
Yes
No
High cholesterol or taking statin drugs
*
Yes
No
Diabetes
*
Yes
No
Stomach or duodenal ulcer
*
Yes
No
Digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)
*
Yes
No
Osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates)
*
Yes
No
Arthritis or gout
*
Yes
No
Autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)
*
Yes
No
Glaucoma
*
Yes
No
Contact lenses
*
Yes
No
Head or neck injuries
*
Yes
No
Epilepsy, convulsions (seizures)
*
Yes
No
Neurologic disorders (e.g. Alzheimer's disease, dementia, prion disease)
*
Yes
No
Viral infections and cold sores
*
Yes
No
Any lumps or swelling in the mouth
*
Yes
No
Hives, skin rash, hay fever
*
Yes
No
STI/STD/HPV
*
Yes
No
Hepatitis
*
Yes
No
HIV/AIDS
*
Yes
No
Tumor, abnormal growth
*
Yes
No
Radiation therapy
*
Yes
No
Chemotherapy, immunosuppressive medication
*
Yes
No
Emotional difficulties
*
Yes
No
Psychiatric treatment or antidepressant medication
*
Yes
No
Concentration problems or ADD/ADHD
*
Yes
No
Alcohol/recreational drug use
*
Yes
No
ARE YOU:
Presently being treated for any other illness
*
Yes
No
Aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea)
*
Yes
No
Taking medication for weight management
*
Yes
No
Taking dietary supplements, vitamins, and/or probiotics
*
Yes
No
Often exhausted or fatigued
*
Yes
No
Experiencing frequent headaches or chronic pain
*
Yes
No
A smoker, smoked previously or other (e.g. smokeless tobacco, vaping, e-cigarettes, and cannabis)
*
Yes
No
Considered a touchy/sensitive person
*
Yes
No
Often unhappy or depressed
*
Yes
No
Taking birth control pills
*
Yes
No
Currently pregnant
*
Yes
No
Diagnosed with a prostate disorder
*
Yes
No
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)
*
List all medications, supplements, vitamins, and/or probiotics taken within the last two years.
*
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
Patient's Signature
*
Date
*
-
Month
-
Day
Year
Date
Doctor's Signature
Date
-
Month
-
Day
Year
Date
Back
Next
DENTAL HISTORY
Patient Name
*
Nickname
Age
*
Referred by
*
How would you rate the condition of your mouth?
*
Excellent
Good
Fair
Poor
Previous Dentist
*
How long have you been a patient?
*
Months/Years
Date of most recent dental exam
*
-
Month
-
Day
Year
Date
Date of most recent x-rays
*
-
Month
-
Day
Year
Date
Date of most recent treatment (other than a cleaning)
*
-
Month
-
Day
Year
Date
I routinely see my dentist every
*
3 mo.
4 mo.
6 mo.
12 mo.
Not routinely
WHAT IS YOUR IMMEDIATE CONCERN?
*
PLEASE ANSWER YES OR NO TO THE FOLLOWING:
PERSONAL HISTORY
*
Rows
Yes
No
Are you fearful of dental treatment?
Have you had an unfavorable dental experience?
Have you ever had complications from past dental treatment?
Have you ever had trouble getting numb or had any reactions to local anesthetic?
Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?
GUM AND BONE
*
Rows
Yes
No
Do your gums bleed sometimes or are they ever painful when brushing or flossing?
Have you ever had or been told you have gum disease, gum or bone loss between your teeth, or had scaling and root planing?
Have you ever noticed an unpleasant taste or odor in your mouth?
Is there anyone with a history of periodontal disease in your family?
Have you ever experienced gum recession, or can you see more ofthe roots of your teeth?
Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
Have you experienced a burning or painful sensation in your mouth not related to your teeth?
TOOTH STRUCTURE
*
Rows
Yes
No
Have you had any cavities within the past 3 years?
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
Do you have grooves or notches on your teeth near the gum line?
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
Do you frequently get food caught between any teeth?
BITE AND JAW JOINT
*
Rows
Yes
No
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars,or other hard, dry foods?
In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?
Are your teeth becoming more crooked, crowded, or overlapped?
Are your teeth developing spaces or becoming more loose?
Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
Do you place your tongue between your teeth or close your teeth against your tongue?
Doyou chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits
Do you clench or grind your teeth together in the daytime or make them sore?
Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
Do you wear or have you ever worn a bite appliance?
SMILE CHARACTERISTICS
*
Rows
Yes
No
Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size, display)?
Have you ever bleached (whitened) your teeth?
Have you felt uncomfortable or self conscious about the appearance of your teeth?
Have you been disappointed with the appearance of previous dental work?
Patient's Signature
*
Date
*
-
Month
-
Day
Year
Date
Doctor's Signature
Date
-
Month
-
Day
Year
Date
Submit
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