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Home
About Us
TOUR
PATIENT FORMS
- Paperwork For Patients
- Dental Benefits Plan
Contact Us
MY ACCOUNT

Dental History

Name*
Date*
MM slash DD slash YYYY
Reason for visit*
Date of last cleaning
MM slash DD slash YYYY
Last x-rays
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
- Night guard
Have you ever been diagnosed with periodontal disease?*
- Yes
- No
When?
Do You Smoke?*
- Yes
- No
How long have you smoked?
How often do you smoke?
Do You Use Chewing Tobacco?*
- Yes
- No
How long have you used chewing tobacco?
How often do you use chewing tobacco?
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?
Do You Have A Preferred Pharmacy?
Are you pregnant/do you think you might be pregnant?*
Expected Due date
MM slash DD slash YYYY
Have you ever taken a premedication?*
- Yes
- No
For*
Do you have any artificial joints?*
Date of surgery
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*
MM slash DD slash YYYY
Do you have any other medical problems we need to be aware of?*
Signature*
Date*
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”.

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Home
About Us
TOUR
PATIENT FORMS
- Paperwork For Patients
- Dental Benefits Plan
Contact Us
MY ACCOUNT