PATIENT'S DENTAL HEALTH
|Why have you come to see us today? (e.g., pain, check up,
etc.)___________________________ Previous Dentist Name_________________________
Reasons for changing dentists:____________________________________ Last visit ____________________Last cleaning______________________
Have you had any problems with past dental treatment?____________________________________________________________________________
Are you nervous about seeing a dentist c Yes! c No If yes, please tell us why:____________________________________________________________
How often do you brush? ______________________________ Do you floss? c Yes c No How often? _______________________________________
|(Please circle Y for Yes and N for No)
Y N I clench or grind my teeth during the day or while sleeping.
Y N My gums bleed while brushing or flossing.
Y N I like my smile.
Y N I prefer tooth colored fillings.
Y N I avoid brushing part of my mouth due to pain.
| Y N
My gums feel tender or swollen.
Y N I have problems eating.
Y N I have had orthodontics.
Y N I have had a facial or jaw injury.
Y N I want my teeth straighter.
Y N I want my teeth whiter.
|What are your dental
(e.g., appearance, dental health, financial considerations, etc.)
__________________________________________________PATIENT'S MEDICAL HISTORY______________________________________________
|I consider my health to be (Please check one): c Excellent c Good c Fair c Poor
Do you have or have you had any of the following?
Please circle Y for yes or N for no.
1. Y N Heart disease
2. Y N Heart Murmur/Mitral Valve Prolapse
3. Y N Stroke
4. Y N Congenital Heart Lesions
5. Y N Rheumatic Fever
6. Y N Abnormal Blood Pressure
7. Y N Anemia
8. Y N Prolonged Bleeding Disorder
9. Y N Tuberculosis or Lung Disease
10. Y N Asthma
11. Y N Hay Fever
12. Y N Sinus Trouble
13. Y N Epilepsy/Seizures
14. Y N Ulcers
15. Y N Implants/Artificial Joints:
16. Y N I smoke or use Chewing Tobacco. If yes, how much per day?____
How many years?___
17. Y N I have consumed alcohol within the last 24 hours.
18. Y N I usually take an antibiotic prior to dental treatment.
19. Y N Have you ever taken Fen-Phen or Redux?
20. Y N I have had major surgery. Year _________Type of operation ____________________________________________________________
Year ________________Type of operation_________________________
23. Y N Jaundice
24. Y N Hepatitis Type_______
25. Y N Diabetes
26. Y N Excessive Urination and/or Thirst
27. Y N Infectious Mononucleosis ("Mono")
28. Y N Herpes
29. Y N Arthritis
30. Y N Sexually Transmitted/Venereal Diseases
31. Y N Kidney Disease
32. Y N Tumor or Malignancy
33. Y N Cancer/Chemotherapy
34. Y N Radiation/Therapy
35. Y N History of Drug Addiction
36. Y N AIDS
37. Y N Immune Suppressed Disorder
38. Y N Hearing Loss
39. Y N Fainting Spells
40. Y N Glaucoma
41. Y N History of Emotional Nervous Disorder
42. Y N Are you taking birth control
43. Y N Are you or could you be pregnant
|21. Y N Do you have any other medical problem or medical history NOT listed on this form? ________________________________________________ ________________________________________________________________________________________________________________________|
|Are you allergic to any of the following? Please circle Y for yes and N for no
44. Y N Aspirin/ibuprofen
45. Y N Sulfa Drugs/Sulfites/Sulfides
46. Y N Penicillin
47. Y N Codeine
48. Y N Latex, Metals, Plastics
49. Y N Local Anesthetics (Novocaine)
50. Y N Other Medications? Which ones?_____________________
|In case of an emergency, please contact:
Name_____________________________________________ Relationship____________________________ Phone_(___)_____________________
Medical Health Reviewed By:
Doctors Signature Date Patient/Parent or Guardian's Signature Date