Name: Mr/Miss/Mrs./Ms. Dr.
Date of Birth (Day/Month/Year):
Who Referred You To Our Office?
IN CASE OF EMERGENCY, WE SHOULD NOTIFY:
Name of Medical Specialist:
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand.
PLEASE FILL IN THE ENTIRE FORM
Are you currently being treated for any medical condition, or have you been treated within the past year?
When was your last medical checkup?
Has there been any change in your general health in the past year?
Are you taking any medications, non-prescription drugs, or herbal supplements of any kind?
If yes, please list them:
Do you have any allergies? If yes, please list them using the categories below:
Other (e.g., hay fever, seasonal/environmental, foods)
Have you ever had a peculiar or adverse reaction to any medicines or injections?
Do you have or have you ever had asthma?
Do you have or have you ever had any heart or blood pressure problems?
Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e., infective endocarditis), a heart condition from birth (i.e., congenital heart disease), or a heart transplant?
Do you have a prosthetic or artificial joint?
Do you have any conditions or therapies that could affect your immune system (e.g., leukemia, AIDS, HIV, infection radiotherapy, chemotherapy)?
Have you ever had hepatitis, jaundice, or liver disease?
Do you have a bleeding problem or bleeding disorder?
Have you ever been hospitalized for any illnesses or operations?
Do you have or have you ever had any of the following?
Are there any conditions or diseases not listed above that you have or have had?
Are there any diseases or medical problems that run in your family? (e.g., diabetes, cancer, or heart disease)
Do you smoke or chew tobacco products?
Are you nervous during dental treatment?
Are you breastfeeding or pregnant? If pregnant, what is the expected delivery date?
Do you identify as a patient with a disability?
When was your last dental visit?
How often did you visit the dentist before then?
Previous Dentist (Name and Location)
How often do you brush your teeth?
How often do you floss your teeth?
When was the last time you have had dental x-rays taken?
Do your gums bleed while brushing or flossing?
Are your teeth sensitive to hot or cold?
Are your teeth sensitive to sweet or sore?
Do you feel pain in any of your teeth?
Do you have any sores or lumps in or near your mouth?
Have you had any head, neck, or jaw injuries?
Do you clench or grind your teeth?
Do you have frequent headaches?
Do you bite your lips or cheeks frequently?
Have you noticed any loosening of the teeth?
Does food tend to become caught between your teeth?
Have you ever had periodontal treatment (gums)?
Have you ever worn a bite plate or other appliance?
Have you ever had any difficult extractions in the past?
Have you ever had any prolonged bleeding following extractions?
Do you wear dentures or partials?
If yes, date of placement:
Have you ever received oral hygiene instructions regarding the care of your teeth and gums?
Have you ever experienced any of the following problems your jaw:
Pain (joint, ear, site of face)
Difficulty in opening or closing
To the best of my knowledge, the above information is correct:
Patient/Parent/Guardian Signature:
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