Medical And Dental Information History Form Page 2
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1
2
3Bite and Jaw
Do you have any issues chewing gum?
Yes
No
Does chewing bagels or other hard foods cause you any problems?
Yes
No
Have your teeth changed in the last 5 years? Have they become shorter, thinner, or worn?
Yes
No
Do you feel that your teeth are crowding or developing spaces?
Yes
No
Do you have more than one bite or do you clench (squeeze) to make your teeth fit together?
Yes
No
When you go to sleep at night, do you wake up with an awareness of your teeth?
Yes
No
Do you have any problems with your jaw joint? (Pain, sounds, limited opening, locking, popping.)
Yes
No
Do you get tension headaches or do you have sore teeth?
Yes
No
Do you use or have you ever used a bite appliance?
Yes
No
GuM History
Have you been diagnosed with or treated for periodontal disease?
Yes
No
Have you experienced gum recession?
Yes
No
Is there a history of periodontal disease in your family?
Yes
No
Do your gums bleed when brushing, flossing, or eating?
Yes
No
Are your teeth becoming loose?
Yes
No
Have you noticed an unpleasant taste or odor in your mouth?
Yes
No
Do you experience a burning sensation in your mouth?
Yes
No
Do your gums swell and cause you pain?
Yes
No
Have you been diagnosed with or treated for periodontal disease?
Yes
No
Medical History
Personal History
Have you been hospitalized in the past two years?
Yes
No
When was your last visit to a Physician?
Yes
No
Last complete physical examination?
Yes
No
Are you taking any prescription medications?
Yes
No
Are you currently being treated for any other illness?
Yes
No
Physician Name:
Phone Number:
Have you ever reacted adversely to any medications or injections?
Yes
No
Do you use or have you used, tobacco products?
Yes
No
CHeCk ‘yes’ if you Have or Have ever Had any of tHe followinG:
Allergic reaction to:
aspirin, ibuprofen, acetaminophen
erythromycin
Yes
Yes
codeine
latex
Yes
Yes
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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