BlueSky Dentistry

My WordPress Blog

208 882-9111 Follow Us

HOME
ABOUT US
- Meet Our Staff
TOUR
PATIENT FORM
- Paperwork For Patients
- BlueSky Benefit Plan
CONTACT US

Dental History

Name*
Date*
Date Format: MM slash DD slash YYYY
Reason for visit*
Date of last cleaning
Date Format: MM slash DD slash YYYY
Last x-rays
Date Format: MM slash DD slash YYYY
Do you have any of the following? Check those that apply:*
- Sensitivity to hot/cold
- Dry mouth
- Bleeding gums
- Jaw Pain
- Discolored teeth
- Grinding teeth
- Mouth breathing
- Lip or cheek biting
- Removable retainers or dentures
- Crowded teeth
- Bad breath
- Food collection
- Swelling around teeth
- Broken fillings
- Loose teeth
- Braces
- Sore on lips
- Sores inside mouth
- Have you ever been diagnosed with periodontal disease?
- When?
- Do you smoke?
- How long?
- How often?
- Do you use chewing tobacco?
- How long?
- How often?
- Night guard
- N/A
Medical History
Name of Medical Doctor*
Office
Are you taking any medications at this time? Please list name and dosage*
Are you allergic to any of the following? Check all that apply:*
- Penicillin
- Latex
- Codeine
- Foods
- Dental Anesthetic
- Metals/other materials
- N/A
Any other allergies we should be aware of?
Are you pregnant/do you think you might be pregnant?*
Expected Due date
Date Format: MM slash DD slash YYYY
Have you ever taken a premedication?*
For*
Do you have any artificial joints?*
Date of surgery
Date Format: MM slash DD slash YYYY
Have you ever/do you currently use recreational drugs or alcohol?*
- Yes
- No
please indicate what, when, and how much:*
Do you have any of the following? Check those that apply*
- Abnormal blood pressure
- Arthritis or rheumatism
- Asthma or hay fever
- Blood disease or anemia
- Chemotherapy/radiation therapy
- HIV/AIDS
- Jaundice
- Rheumatic fever
- Sinus trouble
- Ulcers
- Prolonged bleeding
- Hepatitis (List type)
- Chronic cough
- Congenital heart lesions
- Epilepsy
- Glaucoma
- Head injury
- Kidney disorder
- Leukemia
- Stroke
- Thyroid condition
- Tumors or growths
- Fainting spells
- STD's (List type)
- Heart disease
- Heart murmur
- Heart pacemaker
- Sleep apnea
- Mitral valve prolapse
- Multiple sclerosis
- Parkinson's disease
- Psychiatric treatment
- Tuberculosis or lung disease
- Excessive urination
- Excessive thirst
- Diabetes (List type)
- Heart Attack
- N/A
Date of Heart Attack*
Date Format: MM slash DD slash YYYY
Do you have any other medical problems we need to be aware of?*
Signature*
Date*
Date Format: MM slash DD slash YYYY
I certify that this is an accurate history of my health.*
- “I certify that this is an accurate history of my health”.

Copyright © 2020 · BlueSky Dental · 2500 W A St Ste 204, Moscow, ID 83843 · (208) 882-9111

Announcement

In an effort to support national efforts to fight the COVID- 19 pandemic, our practice is taking the following steps to help assure your health and well-being and that of our community:

We are following directives from the Centers for Disease Control and Prevention (CDC) as a way to limit patient and staff exposure to this virus.
Your health, and the health of our dedicated staff, matters to us, so going forward we will suspend all non-emergency care.
Patients will be seen only for urgent and emergency dental needs.

During this time when we are unable to schedule routine dental cleanings, we encourage everyone to “ramp up” personal dental homecare. Do not share toothbrushes, use separate floss dispensers, and routinely replace toothbrushes.

The safety and well-being of our patients continues to be our primary concern. We will continue to monitor the status of COVID-19 nationally and within our community and keep you up-to-date regarding our plans to reopen for business as usual.

I urge you to contact us if you have any questions or concerns. We can be reached by phone at 208-882-9111 or by email to info@blueskydentistry.com and will respond as soon as we can. We are open for appointments only.

Thank you,

Dr. Kevin Henry

Click here for “What is a Dental Emergency” information

BlueSky Dentistry

HOME
ABOUT US
- Meet Our Staff
TOUR
PATIENT FORM
- Paperwork For Patients
- BlueSky Benefit Plan
CONTACT US