Howard Family Dental
Medical History
Dental History
Patient Name (please print):____________________________________________________
(Please check any of the following that apply to you)
What would you like to do to improve your smile?
Sensitivity (hot, cold, sweets, pressure)
Whiten
Discomfort when chewing
Straighten
Headaches, earaches, neck pain
Close spaces
Jaw joint pain
Replace silver fillings with tooth colored fillings
Teeth or fillings breaking
Repair chipped teeth
Bad breath/bad taste in mouth
Replace missing teeth
Bleeding, swollen or irritated gums
Replace old crowns that don’t match other teeth
Loose, chipped or shifting your mouth
Grinding or clenching teeth
Do you have or have you ever had any of the following?
How long has it been since your last cleaning?
Dentures Partial Dentures
Less than 1 yr 1-2 yrs 3-5 yrs over 5 yrs
Braces
Periodontal (gum) treatments
What is most important about your visit today? ____________________________________________________________________________
_____________________________________________________
________________________________
_____________________________________
Name of previous dentist
Phone number
City & State
Why did you leave your previous dentist? ___________________________________________________________________________________
___________________________________________________________________________________________________________________________________
Previous dental experiences: __________________________________________________________________________________________________
On a scale of 1 to 10 with 10 being the highest:
How important is your dental health to you?
1 2 3 4 5 6 7 8 9 10
Where would you rate your current dental health?
1 2 3 4 5 6 7 8 9 10
Sleep History
Have you ever had a sleep study or do you currently use a CPAP?
Yes No
Does your partner say that you snore?
Yes No
Do you take frequent naps during the day, or often feel tired?
Yes No
Other: ______________________________________________________________________________________________________
Medical History
Have you been under the care of a medical doctor during the past two years?
Yes No
If yes, for what? _____________________________________________________________________________________________________________
Physician’s name: __________________________________________________ Last visit to Physician: _________________________________
Do you have high blood pressure? Yes No
What is your normal blood pressure? ______________________________
Emergency Contact: ________________________________________________ Phone Number: ____________________________________
Are you allergic or have you had a reaction to the following:
Local Anesthetic
Updates:
Yes No
Penicillin or other antibiotics
Initials ____________ Date ________________
Yes No
Aspirin, Ibuprofen or Tylenol
Initials ____________ Date ________________
Yes No
Codeine, Valium or other sedatives
Initials ____________ Date ________________
Yes No
Latex or metals
Initials ____________ Date ________________
Yes No
Patient Signature: ________________________________________________________________ Date: ______________
Doctor Signature: _________________________________________________________________ Date: _______________