Health and Dental History Form by taylorh@gmail.com on May 28, 2020 0Like Patient First Name* Patient Last Name* Patient/Legal Representative Email Address* Health and Dental History Why are you seeking dental treatment? What is your smile goal? Are you in good health? YesNo Have you ever had excessive bleeding following an extraction? YesNo (Women) Are you pregnant? If yes, give due date YesNo Pregnancy due date (Women) Are you nursing? YesNo Sputum production (phlegm) YesNo Do you use tobacco in any form? If yes, how much YesNo Tobacco usage amount Do you use alcoholic beverages (more than 2 drinks per day)? YesNo Do you use recreational drugs? If yes, what and how often? YesNo Recreational drug usage details Do you use electronic cigarettes (vape)? If yes, how often? YesNo Electronic cigarette usage details Do you have or have you ever had any of the following: GENERAL Difficulty breathing while lying down YesNo Tire easily, weakness YesNo Marked weight change YesNo Persistent fever YesNo SKIN Eruptions (rash) hives YesNo Change in skin color YesNo Visual change YesNo Glaucoma YesNo Dry Eyes YesNo EARS Loss of hearing YesNo Ringing in ears YesNo NOSE Frequent nosebleeds YesNo Sinus problems YesNo THROAT Soreness/hoarseness YesNo Enlarged Tonsils YesNo NERVOUS SYSTEM Stroke (If yes, please date) YesNo Stroke Date Headaches (chronic) YesNo Convulsions/seizures YesNo Numbness/tingling YesNo Dizziness/fainting YesNo Psychiatric treatment YesNo RESPIRATORY Tuberculosis YesNo Emphysema YesNo Asthma/hay fever YesNo Persistent cough YesNo Cough up bloody sputum YesNo BLOOD Bruise Easily YesNo Anemia YesNo Blood transfusion YesNo Blood Disease YesNo ENDOCRINE Diabetes I or II. (If yes, please specify type) YesNo Diabetes Type Thyroid condition/goiter YesNo HEART/BLOOD VESSELS Rheumatic Fever YesNo Heart Murmur YesNo Chest pain/discomfort YesNo Heart attack/trouble. (If Yes, please specify date) YesNo Heart attack date Shortness of Breath YesNo Swelling of ankles YesNo High blood pressure YesNo Congenital heart disease YesNo Mitral valve prolapse YesNo Artificial heart valve YesNo Pacemaker/defibrillator YesNo Heart surgery. (If Yes, please specify date) YesNo Heart surgery date Other (If Yes, please specify) YesNo Other heart/blood issues BONE/MUSCLES Arthritis/rheumatism YesNo Artificial joints/limbs. (If Yes, please specify type) YesNo Add'l artificial joints/limb details DIGESTIVE SYSTEM Hepatitis A, B, or C YesNo Jaundice YesNo Ulcers YesNo Change in appetite YesNo Black, bloody or pale stools YesNo URINARY Kidney disease YesNo Increase in frequency of urination YesNo Burning on urination YesNo Urethral discharge YesNo Bloody urine YesNo Venereal Disease YesNo OTHER Radiation therapy. (If Yes, please specify what for) YesNo Add'l radiation therapy details Chemotherapy. (If Yes, please specify what for) YesNo Add'l chemotherapy details Tumors or growths YesNo Cancer (If Yes, please specify) YesNo Add'l cancer details HIV+ / Aids YesNo Is there any disease, condition or problem not listed above that you think we should know about, or is there any activity your doctor says you cannot do? Please list surgical history: Are you ALLERGIC or have you ever experienced any reaction to the following? Local anesthetics (e.g. novocaine) YesNo Barbiturates/sedatives/sleeping pills YesNo Penicillin YesNo Other antibiotics (list below) YesNo Latex YesNo Are you allergic to aspirin? YesNo Codeine YesNo Sulfa drugs YesNo Other allergies YesNo If yes to any of the above allergy items please elaborate below Are you taking any of the following? Antibiotics/sulfa drugs YesNo Blood thinners YesNo Blood pressure medication YesNo Thyroid medicine YesNo Cortisone/steroids YesNo Antihistamines/allergy drugs YesNo Cold medications YesNo Sedatives YesNo Insulin/other diabetes drugs YesNo Recreational drugs YesNo Digitalis/other heart medications YesNo Nitroglycerin YesNo Aspirin YesNo Other medications YesNo If you answered yes to taking any medications above please list NAME AND DOSAGE of medication: Physicians Name Physicians phone number Have you ever had any serious trouble associated with previous dental treatment? Does dental treatment make you nervous? NoSlightlyModeratelyExtremely Date of last dental visit Have you ever been treated for periodontal disease (gum disease, deep cleaning)? If so, when? Periodontal disease details Do you have or have you ever had any of the following? MOUTH Bleeding, sore gums YesNo Unpleasant taste/bad breath YesNo Burning tongue/lips YesNo Frequent blisters, lips/mouth YesNo Swelling/lumps in mouth YesNo Ortho treatments (braces) YesNo Biting cheeks/lips YesNo Clicking/popping jaw YesNo Difficulty opening or closing jaw YesNo TEETH Loose teeth YesNo Sensitive to hot YesNo Sensitive to cold YesNo Sensitive to sweets YesNo Sensitive to biting YesNo Food impaction YesNo Clenching /grinding YesNo Shifting of teeth YesNo Change in bite YesNo Do you have/noticed any of the following symptoms? Mouth breathing YesNo Dry mouth / throat YesNo Snoring YesNo Daytime fatigue YesNo Restlessness YesNo Irritability YesNo ORAL HYGIENE Toothbrush YesNo Electric toothbrush YesNo How many times do you brush a day? Bristles on my brush are: SoftMediumHard Do you use dental floss? YesNo If yes, how many times a day do you floss? Do you water floss? YesNo How many times do you use a water flosser a day? Fluoride Rinse YesNo Type of Fluoride Rinse Other types of oral hygiene YesNo What other types of oral hygiene? Use of Oral Appliances CPAP Machine YesNo Snoring Appliance YesNo Night guard / Occlusal Guard YesNo Athletic guard YesNo Orthodontic retainer YesNo Any other oral appliances? YesNo If yes, what other oral appliances do you use? By checking the box below I agree that to the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health or change in my medication, I will inform the dentist at the next appointment. Agree* Option 1 Relationship to the patient* PatientParentGrandparentGuardianSiblingLegal Representative Name if not the patient* Posted in
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