Your account information: Step 6 - 7
Dental History
Patient Name
Patient Account No
Medical Alert
What is the reason for visit today?
Previous dentist's name:
Date of the last visit
Last dental cleaning
Last full mouth x-ray
Please select
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
What was done at your last dental visit?
Phone
How often do you have dental examination?
How often do you brush your teeth?
How often do you floss?
What other dental aids do you use? (Interplak, toothpick, etc.)
Do you have dental problem now?
If yes please describe:
Are any of your teeth sensitive too:
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?
Does food tend to become caught in between your teeth?
If yes where:
Do you:
Clench or grid your teeth while awake or asleep?
Bite your lips or cheeks regularly?
Hold foreign objects with your teeth? (Pencil, pipe, pins, nails, fingernails)
Mouth breathe while awake or asleep?
Have tired jaws, especially in the morning?
Smoke chew tobacco?
Have you ever had:
Orthodontic treatment?
Oral surgery?
Periodontal treatment?
Your teeth ground or the bite adjustment?
A bite plate or mouth guard?
A serious injury to the mouth or head?
If so, please describe, including cause
Have you experienced:
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, neck aches or shoulder aches?
Sore muscles (neck, shoulder)?
Are you satisfied with your teeth′s appearance?
Would you like to keep all of your teeth all of your life?
Do you feel nervous about having dental treatment?
If so what is your biggest concern?
Have you ever had an upsetting dental experience?
If so, please describe
Is there anything else about having dental treatment that you would like us to know?
If yes, please describe
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Your account information: Step 7 - 7
Medical History
Patient Name
Patient Account No
Medical Alert
1. Have you been under the care of medical doctor during past two years?
Physician's name
Phone
2. Have you taken any medication or drugs the past two years?
If yes, for what? please list name and dosage
3. Are you taking any medication, drugs or pills now, including regular dosages of aspirin?
Yes
If yes to any of above, did you have a medical exam for heart issues?
Yes
6. Have you been a patient in the hospital during the past five years?
Yes
7. Indicate which of the following you have had, or have at present.
I understand the above information is necessary to provide
me with dental care in safe and efficient manner. I have answer all questions to the best of my knowledge.
Should further information be needed, you have my permission to ask the respective health care provider or
agency, who may release such information to you.
I will notify the doctor of change in my health and medication.
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