Medical Dental History Form Page 2
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1
2PAST DENTAL TREATMENT:
Yes
Yes
68 Alcohol use?
86 One or more fillings in the last three years?
Amount per week:
87 Family history of extensive decay?
How long:
88 If Child, mother’s history of decay?
69 Former tobacco user?
89 Treatment for periodontal (gum) disease?
Type:
90 Family history of periodontal disease?
Year quit:
91 Have you had orthodontics (braces)?
Quit for how long:
92 Have you had oral surgery?
70 Tobacco user?
93 Have you had any dental implants placed?
Type:
94Treatment for tempormandibular disorders?
Amount:
95 Do you wear a denture(s) or partial denture(s)?
71 How soon after wake up do you use tobacco?
DO YOU HAVE CONSISTENT PROBLEMS WITH:
within 5 min
6-30 min
31-60 min
over 60 min
72 Previous attempts to quit
96 Dry mouth/excessive thirst
73 Are you interested in quitting tobacco?
97 Sensitive teeth? Hot Cold Pressure Sweets
98 Mouth odors/bad taste?
DENTAL INFORMATION:
99 Cold sores/blisters/oral lesions?
74 Previous dentist:
75 Last dental visit:
100 Are you aware of any swelling or lumps?
76 Last dental cleaning
101 Sore, bleeding gums?
77 Frequency of dental exams
102 Loose teeth?
78 What made you decide to make this dentist
103 Difficulty chewing?
appointment?
79 Frequency of brushing:
104 Food catches between teeth?
80 Frequency of flossing:
105 Teeth/filling break frequently?
81 What are some typical foods you eat between meals?
106 Clenching or grinding habits?
82 What types of beverages do you typically drink
107 Do you hear popping, clicking or snapping?
between meals?
83 How often do you chew or suck on hard candy,
108 Do you have jaw pain?
cough drops or mints?
84 Do you use fluoridated toothpaste?
Yes
109 Are you nervous about dental work?
85 Primary source of drinking water? (circle)
City water filtered
City water unfiltered
Bottled water
Well water
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