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THE ANWERS TO THE FOLLOWING QUESTIONS HELP OUR DENTISTS EVALUATE YOUR GENERAL HEALTH PRIOR TO PROVIDING YOU WITH DENTAL TREATMENT.

PLEASE READ CAREFULLY AND ANSWER EACH QUESTION AS ACCURATELY AS POSSIBLE.

1. In general, how is your present health?
2. What month and year did you have your last physical examination?

Please check each of the following medical conditions that you currently have or had in the past. If you check any box please explain in the Additional Details box.

 
Additional Details:

Please check Yes or No for the following questions. If you answer Yes to any question, please provide details in the Patient Comments box.

1. Are you presently or have you been under the care of a physician during the past year? Yes       No
2. Are you presently taking any medications? Yes       No
3. Are you allergic to any medication or other materials? Yes      No
4. Have you ever had a reaction to a local anesthetic? Yes      No
5. Have you ever experienced any complications or illness following dental treatment? Yes      No
6. Do you have any disease or health conditions not listed above? Yes      No
7. Have you ever been told you were not eligible to be a blood donor? Yes      No
8. Do you use tobacco? Yes      No (if yes, please check product and give frequency)
   SMOKE:
   Cigarettes
   Vapor Cigarettes
   Cigars
   Pipe
   SMOKELESS:
   Chewing Tobacco
   Snuff or “Dip”
   FREQUENCY:
9. WOMEN ONLY: Are you or could you be pregnant? Yes      No
   (if yes, check which trimester) 1      2      3

Patient Comments:

TELL US ABOUT YOUR DENTAL HISTORY

Please check Yes or No for the following questions. If you answer Yes to any question, please provide details in the Patient Comments box.

1. Do your gums presently bleed when you brush or floss your teeth? Yes      No
2. Are you teeth sensitive to hot or cold liquids or food? Yes      No
3. Are your teeth sensitive to sweet or sour liquids or food? Yes      No
4. Do you presently feel pain with any of your teeth? Yes      No
5. Do you presently have any sores or lumps in or near your mouth? Yes      No
6. Have you ever had any head, neck or jaw injuries? Yes      No
7. Have you ever experienced any of the following conditions in your jaw? Yes      No
1. Clicking? Yes      No
2. Pain (joint, ear or side of face)? Yes      No
3. Difficulty in opening or closing your mouth? Yes      No
4. Difficulty in chewing? Yes      No
8. Do you have frequent headaches? Yes      No
9. Do you clench or grind your teeth? Yes      No
10. Do you frequently bite your lips or cheeks? Yes      No
11. Have you ever had any difficulty with teeth extractions in the past? Yes      No
12. Have you ever had any orthodontic treatment? Yes      No
13. Have you ever had prolonged bleeding following teeth extractions? Yes      No
14. Had you received instructions on how to brush your teeth? Yes      No
15. Have you ever been given instructions on how to care for your gums? Yes      No

Patient Comments:

By my signature below, I acknowledge that I have fully read and understand the above medical history questions. In addition, to the best of my knowledge, I have accurately and completely answered the above questions. I further acknowledge that providing incorrect information and/or answers can be detrimental (risk) to my health.

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Note: A copy of this completed form will be emailed to you for your records.