Name:
1. Are you under medical treatment now? YesNo
2. Are you currently taking drugs or medication? YesNo List drug and condition for which you take it.
3. Do you have any drug allergies? YesNo List drugs and reaction.
4. Do you smoke or use tobacco products? YesNo How long? Quit Date:
5. Have you ever been hospitalized? YesNo Explain.
6. Have you ever had abnormal bleeding problems after a cut or tooth extraction? YesNo
7. Indicate which of the following you have had or have at the present:
heart murmurrheumatic feverartificial heart valveartificial joint (knee/hip)heart disease or attackanginahigh blood pressurecongenital heart lesionsheart surgeryanemiastrokekidney troubleemphysemaasthmasinus trouble
diabetesthyroid diseasecancerchemotherapycobalt treatmentarthritisHIV/ AIDShepatitisliver diseaseblood transfusiondrug addictionhemophiliavenereal diseaseepilepsy, seizuresfainting, dizzinesspsychological or psychiatric treatment
Women: Pregnant? YesNo If so, which trimester? 123
Dental History
1. Please state briefly the reason for your visit.
2. Do you have discomfort in your mouth now? YesNo
3. Do you have any swelling in your mouth? YesNo
4. Do you have any sore spots, ulcerations or growths in your mouth? YesNo
5. Are your teeth sensitive to hot, cold or sweets? YesNo
6. Are any of your teeth loose? YesNo
7. Do your gums bleed, or do they feel irritated? YesNo
8. Do you have an unpleasant taste in your mouth? YesNo
9. Do you have pain in your jaw joint? YesNo
10. Do you grind or clench your teeth? YesNo
11. Does your jaw click with opening or closing? YesNo
12. Have you ever had teeth extracted? YesNo
13. Have you ever had a root canal? YesNo
14. Have you ever had gum treatments? YesNo
15. Have you ever worn braces? YesNo
16. Do you wear dentures or plates? YesNo
17. What type of toothbrush do you use? HardSoft
18. Do you floss? YesNo How often?
19. How long has it been since your last dental visit?
20. What was the reason for your last dental visit?
21. Are you nervous to receive dental treatments? Not at AllModerateVery
22. Have you had any problems receiving dental care? YesNo
23. Is there anything that you could tell us that would benefit us in treating your dental needs?
I understand that the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions truthfully and to the best of my knowledge.
In case of an emergency, I authorize the doctor to perform treatments and administer medications and to employ assistance as she deems necessary.
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