Medical History Form Page 2
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1
2Dental Health History
Please answer only those questions that apply, if not sure of your answer, place “?” and discuss w/ Dr.
Reason for visit: _________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Date of last dental visit? ______________What was done?________________________________________________________________
_______________________________________________________________________________________________________________
Former Dentist Name, Address, and Phone:____________________________________________________________________________
Current or Recent Dental Specialists Name and phone:___________________________________________________________________
_______________________________________________________________________________________________________________
Last Full Mouth Xrays_______________(full set =14+ xrays) Digital - Yes No Last Cleaning appt? _________ How Often?_________
Last Deep Scaling for gum disease:__________________By Whom?______________________ Last Gum Surgery? ________________
Additional Notes:_________________________________________________________________________________________________
_______________________________________________________________________________________________________________
What do you NOT like about the appearance of your smile?_______________________________________________________________
_______________________________________________________________________________________________________________
What would you like to change about your smile?_______________________________________________________________________
_______________________________________________________________________________________________________________
When did you last whiten your teeth?___________How Often do you touch up whiten?________Brand of Whitener? _________________
Additional Notes:_________________________________________________________________________________________________
When did you have Orthodontic (Braces) Treatment? __________________Years in Treatment? ____________Retainers worn?________
Orthodontist Name and info: ________________________________________________________________________________________
When did you have the following:
Head or Neck Injury such as fall or car accident?__________________________ Treatment?____________________________________
Jaw or teeth injuries?_____________________ Treatment? ______________________________________________________________
How do you still suffer from these injuries? ____________________________________________________________________________
Continued treatment? _____________________________________________________________________________________________
Dental Anxiety and Fear:
How does Dental treatment make you nervous? _________________________________________________________________________
What bad experiences or problems have you had at the dentist? ____________________________________________________________
_______________________________________________________________________________________________________________
What helps make you more comfortable when going to the dentist? _________________________________________________________
_______________________________________________________________________________________________________________
Have you ever had a bad reaction to dental anesthetic? Please describe: ______________________________________________________
_______________________________________________________________________________________________________________
Oral hygiene Habits: please be accurate
When do you brush your teeth?_______________ What type of brush do you use? (circle) Manual or Electric / Brand name?___________
When do you floss?________________Brand name? ______________ Do your gums bleed.., when brushing? _____when flossing? _____
What areas do you avoid when brushing or flossing? ________________________Why? _______________________________________
WHERE do you have PAIN with the following? :
HOT FOODS OR LIQUIDS? ____________________________________________ Circle: Sharp Dull Achey Pain lingers
How often does this occur?________________________ What makes it feel better?___________________________________________
COLD FOODS OR LIQUIDS? ___________________________________________ Circle: Sharp Dull Achey Pain lingers
How often does this occur?________________________ What makes it feel better?___________________________________________
SWEETS OR SOUR? __________________________________________________ Circle: Sharp Dull Achey Pain lingers
How often does this occur?________________________ What makes it feel better?___________________________________________
Where do you have pain on BITE PRESSURE?______________________________ Circle: Sharp Dull Achey Pain lingers
How often does this occur?___________________Which side do you chew on?_______________ Why? __________________________
Where are your gums tender or swollen? ______________________________________________________________________________
When you do clench or grind your teeth? _______________________When do your jaws feel tired? ______________________________
Do you wear a bite guard?
Yes No When? _______________ Type of Guard? ______________ How Often? ___________________
Do you have many cavities? Yes No
Do you lose or break fillings? Yes No
Do you gag easily?
Yes No
What does the term preventive dentistry mean to you? ___________________________________________________________________
PARTIAL and FULL DENTURES Info:
Age of Partial or Full Dentures? UPPER Year Placed?________________ Last relined? ______________ Any repairs? ______________
___________________________ Problems you feel? ___________________________________________________________________
LOWER Year Placed?_______________ Last relined? ________________ Any repairs? _______________________________________
Problems you feel? _______________________________________________________________________________________________
Please add any dental or mouth problems you are concerned about:
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
Additional Dental History Notes : ___________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_____________________________________________________
Date:
Patient or Guardian Signature:
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