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Search for:
ABOUT US
TREATMENTS
RESOURCES
BLOG
FORMS
FOR PATIENTS
FOR DENTISTS
CONTACT
BOOK NOW
ABOUT US
TREATMENTS
RESOURCES
BLOG
FORMS
FOR PATIENTS
FOR DENTISTS
CONTACT
BOOK NOW
Dental History Form
Dental History Form
dev@medianv.com
2022-02-05T11:14:59-07:00
Patient Dental History
Patient First Name
*
Patient Last Name
*
Email Address
*
Phone Number
*
Referred by
Previous Dentist
For how long?
I have routinely seen my dentist every
3-4 Months
6 Months
12 Months
Not often
How would you rate the condition of your mouth?
*
Excellent
Good
Fair
Poor
What is your immediate concern?
*
Are you fearful of dental treatment?
*
Please select an option
Yes
No
How fearful? (1-10)
1
2
3
4
5
6
7
8
9
10
Have you ever had an unfavorable dental experience?
*
Please select an option
Yes
No
Have you ever had complications from past dental treatment?
*
Please select an option
Yes
No
Have you ever had trouble getting numb or had any reactions to local anesthesia?
*
Please select an option
Yes
No
Did you ever have braces, orthodontic treatment, or have your bite adjusted?
*
Please select an option
Yes
No
If yes, at what age?
Have you had any teeth removed, missing teeth that never developed, or lost teeth due to injury or facial trauma?
*
Please select an option
Yes
No
Gum and Bone
Please select all that apply to you:
Bloody or painful gums when brushing or flossing
Previous gum disease or bone loss around teeth
Unpleasant taste or odor in mouth
Family history of periodontal disease
Gum recession
Loose teeth (without any injury) or difficulty eating an apple
Burning sensation or pain in mouth not related to teeth
Tooth Structure
Please select all that apply to you:
Cavities within the past 3 years
Amount of saliva seems to be too little or difficulty swallowing food
Holes on the biting surface of teeth
Teeth are sensitive to hot, cold, biting, sweets, or brushing
Teeth have grooves/notches near gumline
Broken teeth, chipped teeth, or cracked filling causing toothache
Food often gets caught in between teeth
Bit and Jaw Joint
Please select all that apply to you:
You have problems with your jaw joint (pain, sounds, limited opening, locking, popping)
You feel like your lower jaw has to push back when you bite your back teeth together
You avoid or have difficulty chewing gum, carrots, nuts, bread, protein bars, or other hard, dry foods
Your teeth have changed in the past 5 years (shorter, thinner, worn) or you bite has changed
Your teeth are becoming more crooked, crowded, or overlapped
Your teeth are developing spaces or becoming more loose
You have trouble finding your bite or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together
You place your tongue in between your teeth or close your teeth against your tongue
You chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits
You clench or grind your teeth together in daytime or make them sore
You have problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache, or an awareness of your teeth
You wear or have worn a bite appliance
Smile Characteristics
Please select all that apply to you:
There is something about the appearance of your teeth you would like to change (shape, colour, size)
You have whitened (bleached) your teeth
You have felt uncomfortable or self-conscious about your teeth appearance
You have been disappointed about the appearance of previous dental work
Medical History
Name of physician and their specialty
Most recent physical examination and purpose
What is your estimate of your general health?
Excellent
Good
Fair
Poor
Do you or have you ever had hospitalization for illness or injury?
Yes
No
If yes, please specify the reason:
Do you or have you ever had an allergic or bad reaction to any of the following:
Aspirin, Ibuprofen, Acetaminophen, Codeine
Penicillin
Erythromycin
Tetracycline
Sulfa
Local Anesthetic
Fluoride
Metals (Nickel, Gold, Silver)
Latex
Nuts
Fruit
Other
If other, please specify:
Please select all of the following that you have or have ever had:
Heart problems or cardiac stent within last 6 months
History of infective endocarditis
Artificial heart valve, repaired heart defect
Pacemaker, implantable defibrillator
Orthopedic implant (joint replacement)
Rheumatic or scarlet fever
High or low blood pressure
A stroke (taking blood thinners)
Anemia or other blood disorders
Prolonged bleeding due to a slight cut (INR > 3.5)
Pneumonia, emphysema, shortness of breath, sarcoidosis
Tuberculosis, measles, or chicken pox
Asthma
Breathing or sleeping problems (i.e. sleep apnea, snoring, or sinus)
Kidney disease
Liver disease
Jaundice
Thyroid, parathyroid disease, or calcium deficiency
Hormone deficiency
High cholesterol or taking statin drugs
Diabetes (HbA1c)
Stomach or duodenal ulcer
Digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)
Osteoporosis or osteopenia (i.e. taking biphosphates)
Arthritis
Autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma)
Glaucoma
Contact lenses
Head or neck injury
Epilepsy or convulsions (seizures)
Neurological disorders (ADD, ADHD, prion disease)
Viral infections or cold sores
Any lumps or swelling in the mouth
Hives, skin rash, hay fever
STI / STD / HPV
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
HIV / AIDS
Tumor or abnormal growth
Radiation therapy
Chemotherapy or immunosuppressive medication
Emotional difficulties
Psychiatric treatment
Antidepressant medication
Alcohol / recreational drug use
Please explain and date the above selected items:
Please select any of the following that apply to you:
Presently being treated for any other illness
Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)
Taking medication for weight management
Taking dietary supplements
Often exhausted or fatigued
Experiencing frequent headaches
A smoker, previously smoked, or use smokeless tobacco
Often unhappy or depressed
On a form of birth control
Currently pregnant/breast-feeding
Diagnosed with prostate cancer
Please explain and date the above selected items:
Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your treatment:
List all medications, supplements, and/or vitamins taken within the last two years:
Please advise the office in the future of any change(s) in your medical or dental history as well as medications you may be taking.
SUBMIT
Please do not fill in this field.
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