Medical And Dental Information History Form

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Medical and dental inforMation History forM
Patient Name:
Age:
Name of guardian (if required):
Address:
Phone Number:
Work Phone:
Ext:
Mobile Phone:
Date of Birth: (MM/DD/YYYY)
Are your family members patients at this clinic?
Yes
No
Names:
dental History
Personal History
Does the prospect of dental treatment make you apprehensive?
Yes
No
Have you had a negative dental experience?
Yes
No
Have you ever had complications from previous dental treatments?
Yes
No
When using local anesthetic, do have difficulty getting numb or have you had an adverse reaction?
Yes
No
Did you previously have braces, orthodontic treatment, or have your bite adjusted?
Yes
No
Have any of your teeth been removed?
Yes
No
When was your last dental cleaning/oral hygiene appointment?
Yes
No
When was your last dental visit?
When was your last set of x-rays taken?
Have you been advised to take antibiotics before a dental appointment?
Yes
No
teetH/MoutH History
Do you floss every day?
Yes
No
How many times a day do you brush?
Is there anything about your teeth or smile that you would like to change?
Yes
No
Have you ever whitened your teeth?
Yes
No
Do you find that you are self conscious about your teeth?
Yes
No
Have you had any cavities within the past 3 years?
Yes
No
Do you have a dry mouth?
Yes
No
Are any of your teeth sensitive to hot, cold, biting, or sweets?
Yes
No
Have you ever had a toothache, cracked filling, broken, chipped, or cracked tooth?
Yes
No
Are there any parts of your mouth you avoid brushing?
Yes
No
Do you have any growths or sore spots in your mouth?
Yes
No
Southridge Dental Centre | #101 - 5911 O’Grady Rd., Prince George BC, V2N 6Z5
p: (250) 964-3799 | e: southridgedental@shaw.ca

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