What is the reason for your visit today ?
Date of last dental visit
How often do you have dental examinations?
Last full mouth x-rays
What was done at your last dental visit?
Previous Dentist’s Name
Last dental cleaning
Telephone
How often do you brush your teeth?
How often do you floss?
Do you have any dental problems now?
Yes
No What other aids do you use?
If yes, please describe:
Last dental cleaning
Are any of your teeth sensitive to:
Hot or Cold?
Yes
No Sweets?
Yes
No
Biting or Chewing?
Yes
No Have you noticed any mouth odours or bad tastes?
Yes
No
Do you frequently get sores, blisters or any other oral lesions?
Yes
No Do your gums bleed or hurt?
Yes
No
Have you noticed any loose teeth or change in your bite?
Yes
No Have your parents experienced gum disease or tooth loss?
Yes
No
Does food tend to become caught between your teeth?
Yes
No
If yes, where?
Do you:
Clench or grind your teeth while awake or asleep?
Yes
No Hold foreign objects in your teeth?
Yes
No
(pencils, pipe, pins, nails, fingernails)?
Yes
No Have tired jaws, especially in the morning?
Yes
No
Breathe through your mouth while awake or asleep?
Yes
No Smoke?
Yes
No
Have you ever had:
Orthodontic Treatment?
Yes
No Oral Surgery?
Yes
No
Periodontal Treatment?
Yes
No A bite plate or a mouthguard?
Yes
No
Any previous problems with dental infections?
Yes
No A serious injury to the mouth or head?
Yes
No
If so, please describe, including cause?
Have you experienced:
Clicking or popping of the jaw?
Yes
No Pain (joint, ear, side of face)?
Yes
No
Headaches or shoulder aches?
Yes
No Difficulty in opening or closing the mouth?
Yes
No
Difficulty in chewing on either side of the mouth?
Yes
No Are you satisfied with your teeth’s appearance?
Yes
No
Would you like to keep all your teeth all your life?
Yes
No Do you feel nervous about having dental treatment?
Yes
No
Have you ever had an upsetting dental experience?
Yes
No If so, what is your biggest concern?
Yes
No
If yes, please describe
1. Have you taken any medication or drugs during the past two years?
Yes
No
2. Are you taking any medication, drugs or pills now?
Yes
No
If yes, please list name and dosage:
Are you aware of having an allergic (or adverse) reaction to any medication or substance?
Yes
No
If yes, please list:
Have you been a patient in the hospital during the past five years?
Yes
No
5. Indicate which of the following you have had, or have at present. Circle “yes” or “no” to each item.
Heart (Surgery, Disease, Attack)
Yes
No Stroke
Yes
No
Chest Pain
Yes
No Hepatitis
Yes
No
Thyroid Problems
Yes
No Diabetes
Yes
No
Heart Murmur
Yes
No A.I.D.S
Yes
No
High Blood Pressure
Yes
No Glaucoma
Yes
No
Mitral Valve Prolapse
Yes
No Haemophilia
Yes
No
Artificial Heart Valve
Yes
No Emphysema
Yes
No
Heart Pacemaker
Yes
No Chronic Cough
Yes
No
Rheumatic Fever
Yes
No Tuberculosis
Yes
No
Liver Disease
Yes
No Asthma
Yes
No
Cortisone Medicine
Yes
No H.I.V Positive
Yes
No
Allergies or Hives
Yes
No Latex Sensitivity
Yes
No
Neurological Disorders
Yes
No Congenital Heart Disease
Yes
No
Epilepsy or Seizures
Yes
No Psychiatric/Psychological Care
Yes
No
Fainting or Dizzy Spells
Yes
No Chemotherapy
Yes
No
Yellow Jaundice
Yes
No Tumors
Yes
No
Artificial Joints (hip, knee, etc)
Yes
No Kidney Trouble
Yes
No
Radiation Therapy
Yes
No Blood Transfusion
Yes
No
Sinus Trouble
Yes
No
6. Do you have or have you had any disease, condition, or problem not listed
Yes
No
If yes, please list:
