Dental History Form
Patient's First Name*
Middle Name/Initial
Last Name*
Date of Birth*
Please check any of the following problems that apply to you:
(Check all that apply)
Sensitivity (hot, cold, sweet)
Tooth pain or discomfort when chewing
Headaches, ear aches, neck pain
Mouth ulcers or cold sores
Jaw joint pain
Broken tooth or fillings
Grinding or clenching teeth
Bleeding, swollen or irritated gums
Loose, tipped or shifted teeth
Bad breath or bad taste in your mouth
Do you have or have you had any of the following?:
Dentures
Braces
Gum treatments
Required to take antibiotics prior to dental treatment
Please share the following dates:
Your last cleaning:
Your last complete x-rays:
Name of Previous Dentist:
Phone:
City:
State:
Why did you leave your previous dentist?
What is the most important thing to you about your future Smile and dental health?
Do you smoke or use chewing tobacco? How much? For How long?
If you could change your smile, you would:
Make my teeth whiter
Make my teeth straighter
Close spaces
Replace metal fillings with tooth colored fillings
Repair chipped teeth
Replace missing teeth
Replace old crowns that don’t match
Have a smile makeover
Implants
On a scale of 1-10, with 10 being the highest rating:
How important is your dental health to you?
-- Please select from 1-10 --
1
2
3
4
5
6
7
8
9
10
Where would you rate your current dental health?
-- Please select from 1-10 --
1
2
3
4
5
6
7
8
9
10
What is the most important thing to you about your dental visit today?
MEDICAL HISTORY
Allergies (Seasonal)
Anemia
Artificial Heart Valve
Artificial Joints
Asthma
Blood Disease
Bruise Easily
Cancer
Chemotherapy
Diabetes
Dizziness/Fainting
Marijuana Use
Recreational Drug Use
Excessive Bleeding
Glaucoma
Heart Conditions
Heart Murmur
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
HIV/AIDS
Jaundice
Kidney Disease
Liver Disease
Obstructive Sleep Apnea
Nervousness
Depression
Pacemaker
Phen Fen (1 month +)
Radiation (head/neck)
Respiratory Problems
Rheumatic Fever
Rheumatism
Scarlet Fever
Seizures
Stomach Problems
Stroke
Tuberculosis
Thyroid Disease
Mitral Valve Prolapse
Emphysema
Ulcers
Pregnant
Have you ever taken Bisphosphonates? (i.e. Aredia, Fosamax, Boniva)
Other
Please describe:
Do you have an allergy to any of the following?
Aspirin
Erythromycin
Latex
Local Anesthetic
Nitrous Oxide
Penicillin
Codeine
Other
What surgeries have you had? Please include dates.
What medications/supplements/over the counter medications are you taking?
Name of Family Physician:
Phone:
Are you under a physician’s care? For what?
Have you ever been a victim of abuse and neglect?
Yes
No
Are you currently a victim of abuse and neglect?
Yes
No
Patient Signature or Parent or Guardian Signature (if patient is a minor):
Date: