Dental/medical History And Preferences Form
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1PATIENT NAME
DATE
DENTAL/MEDICAL HISTORY AND PREFERENCES
How often do you brush?
x per day
How often do you floss?
x per week
What type of toothbrush do you use?
Manual:
Soft
Medium
Hard
Electric:
Yes
No
Have you ever had clicking, popping, or discomfort in your jaw joint?
Have you had orthodontics in the past?
Do you wear a retainer now?
Would you like cosmetics options discussed with you?
Do you have any specific dental issues you would like to discuss?
Specific issues:
Are you currently under a physician’s care?
Reason:
Have you ever had any serious illnesses or been hospitalized?
Reason:
Have you ever been instructed to take antibiotics before a dental procedure?
Reason:
Do you now have, or have you ever had, any of the following?
Artificial heart valve
Infective endocarditis
Surgery for a congenital (present from birth) heart condition
Joint replacement – Date(s) of replacement
Are you currently taking any medications?
Medications:
Do you have allergies (medication, latex, acrylics, pollen, dander, etc.)?
Allergies:
If you are female, are you pregnant? – Number of weeks pregnant
SIGNIFICANT FINDINGS (Office Use):
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Parent category: Medical