How did you find us (Required) Gender
In case of EMERGENCY, We should notify:
Primary Insurance Company Information
Secondary Insurance Company Information
Marital Status: Medical History
The following information is required to enable us to provide you with the best possible dental care. All information in the medical and dental history is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
Do you have or have you ever had any of the following: Are there any conditions or diseases not listed above that you have or have had?
Do you have any allergies or sensitivities to any:
Are you taking any medications, non-prescription drugs or herbal supplements of any kind? Has your physician ever told you to take antibiotics prior to dental procdure? Have you ever experienced complications following a medical or dental procedure? Are you currently being treated for any medical condition or have you been treated within the past year? Do you have or have you ever had a replacement or repair of a heart valve, an infection of the heart (i.e. infective endocarditis), a heart condition from birth (i.e. congenital heart disease) or a heart transplant? Have you ever been hospitalized for any illnesses or operations? Do you identify as a patient with a disability? Are you Pregnant? Are you breastfeeding? Do you smoke or chew tobacco products? Has there been any change in your general health in the past year?
To the best of my knowledge, the above information is correct.
Patient/Parent/Guardian Signature: Dental History Questionnaire 2 . Have you been seeing a dentist regularly? 3 . Are you nervous during dental visits? 4 . Have you had a bad experience or complications during dental treatment? 7. Do your gums bleed when you brush or floss? 8 . Do you feel that you have bad breath? 9 . Are you happy with the appearance of your teeth? 10 . Are you happy with your smile? 11.1. Have you ever whitened your teeth? 11.2. Are you interested in whitening? 12 . Is there anything about the appearance of your teeth that you would like to change? 13 . Are you self conscious about your teeth? 14 . Do you have any problems with your jaw (clicking, limited movement, pain)? 15 . Have you ever had an injury to the teeth or jaws or been involved in a motor vehicle accident? Patient/Parent/Guardian Signature: