Patient Dental HistoryPatient First Name *Patient Last Name *Email Address *Phone Number *Referred byPrevious DentistFor how long?I have routinely seen my dentist every3-4 Months6 Months12 MonthsNot oftenHow would you rate the condition of your mouth? *ExcellentGoodFairPoorWhat is your immediate concern? *Are you fearful of dental treatment? *Please select an optionYesNoHow fearful? (1-10)12345678910Have you ever had an unfavorable dental experience? *Please select an optionYesNoHave you ever had complications from past dental treatment? *Please select an optionYesNoHave you ever had trouble getting numb or had any reactions to local anesthesia? *Please select an optionYesNoDid you ever have braces, orthodontic treatment, or have your bite adjusted? *Please select an optionYesNoIf yes, at what age?Have you had any teeth removed, missing teeth that never developed, or lost teeth due to injury or facial trauma? *Please select an optionYesNoGum and BonePlease select all that apply to you:Bloody or painful gums when brushing or flossingPrevious gum disease or bone loss around teethUnpleasant taste or odor in mouthFamily history of periodontal diseaseGum recessionLoose teeth (without any injury) or difficulty eating an appleBurning sensation or pain in mouth not related to teethTooth StructurePlease select all that apply to you:Cavities within the past 3 yearsAmount of saliva seems to be too little or difficulty swallowing foodHoles on the biting surface of teethTeeth are sensitive to hot, cold, biting, sweets, or brushingTeeth have grooves/notches near gumlineBroken teeth, chipped teeth, or cracked filling causing toothacheFood often gets caught in between teethBit and Jaw JointPlease select all that apply to you:You have problems with your jaw joint (pain, sounds, limited opening, locking, popping)You feel like your lower jaw has to push back when you bite your back teeth togetherYou avoid or have difficulty chewing gum, carrots, nuts, bread, protein bars, or other hard, dry foodsYour teeth have changed in the past 5 years (shorter, thinner, worn) or you bite has changedYour teeth are becoming more crooked, crowded, or overlappedYour teeth are developing spaces or becoming more looseYou have trouble finding your bite or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit togetherYou place your tongue in between your teeth or close your teeth against your tongueYou chew ice, bite your nails, use your teeth to hold objects, or have any other oral habitsYou clench or grind your teeth together in daytime or make them soreYou have problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache, or an awareness of your teethYou wear or have worn a bite applianceSmile CharacteristicsPlease select all that apply to you:There is something about the appearance of your teeth you would like to change (shape, colour, size)You have whitened (bleached) your teethYou have felt uncomfortable or self-conscious about your teeth appearanceYou have been disappointed about the appearance of previous dental workMedical HistoryName of physician and their specialtyMost recent physical examination and purposeWhat is your estimate of your general health?ExcellentGoodFairPoorDo you or have you ever had hospitalization for illness or injury?YesNoIf yes, please specify the reason:Do you or have you ever had an allergic or bad reaction to any of the following:Aspirin, Ibuprofen, Acetaminophen, CodeinePenicillinErythromycinTetracyclineSulfaLocal AnestheticFluorideMetals (Nickel, Gold, Silver)LatexNutsFruitOtherIf other, please specify:Please select all of the following that you have or have ever had:Heart problems or cardiac stent within last 6 monthsHistory of infective endocarditisArtificial heart valve, repaired heart defectPacemaker, implantable defibrillatorOrthopedic implant (joint replacement)Rheumatic or scarlet feverHigh or low blood pressureA stroke (taking blood thinners)Anemia or other blood disordersProlonged bleeding due to a slight cut (INR > 3.5)Pneumonia, emphysema, shortness of breath, sarcoidosisTuberculosis, measles, or chicken poxAsthmaBreathing or sleeping problems (i.e. sleep apnea, snoring, or sinus)Kidney diseaseLiver diseaseJaundiceThyroid, parathyroid disease, or calcium deficiencyHormone deficiencyHigh cholesterol or taking statin drugsDiabetes (HbA1c)Stomach or duodenal ulcerDigestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)Osteoporosis or osteopenia (i.e. taking biphosphates)ArthritisAutoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma)GlaucomaContact lensesHead or neck injuryEpilepsy or convulsions (seizures)Neurological disorders (ADD, ADHD, prion disease)Viral infections or cold soresAny lumps or swelling in the mouthHives, skin rash, hay feverSTI / STD / HPVHepatitis AHepatitis BHepatitis CHepatitis DHepatitis EHIV / AIDSTumor or abnormal growthRadiation therapyChemotherapy or immunosuppressive medicationEmotional difficultiesPsychiatric treatmentAntidepressant medicationAlcohol / recreational drug usePlease explain and date the above selected items:Please select any of the following that apply to you:Presently being treated for any other illnessAware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)Taking medication for weight managementTaking dietary supplementsOften exhausted or fatiguedExperiencing frequent headachesA smoker, previously smoked, or use smokeless tobaccoOften unhappy or depressedOn a form of birth controlCurrently pregnant/breast-feedingDiagnosed with prostate cancerPlease explain and date the above selected items:Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your treatment:List all medications, supplements, and/or vitamins taken within the last two years:Please advise the office in the future of any change(s) in your medical or dental history as well as medications you may be taking.SUBMITPlease do not fill in this field.
