Signature Required:
Yes
No
Submission
Assignment
Non-Assignment
Secondary Dental Insurance
Relationship
DOB
Employer
Occupation
Insurance Carrier
Group/Policy #
Signature Required:
Yes
No
Submission
Assignment
Non-Assignment
Dental History
Please appropriate boxes
1. When was your last cleaning and check-up appointment?
2. Are any of our teeth sensitive to
Cold
Sweet
Heat
Other
3. Do your gums bleed when
Brushing
Flossing
Spontaneously
4.Do you suffer from pain and /or swelling of your gums?
Yes
No
5.Are you aware of any loose teeth?
Yes
No
6.Do you chew on only one side of your mouth?
Yes
No
7.Habits
Do you chew gum?
Bite your lips or cheeks regularly?
Grind or clench your teeth during the day or night?
Hold any foreign objects with your teetn? eg. pencils
Mouth breathe while awake or asleep?
Bite your nails?
8.Does any part of your mouth hurt when clenched?
Yes
No
9.Does your jaw crack or pop when opened widely?
Yes
No
10.Do you have any difficulty in opening or closing your jaw?
Yes
No
11.Have you had any of the following:
Oral Surgery
Gum Surgery
Braces
Other appliances
12.Have you experienced any growth or sore spots in your mouth
Yes
No
13.Are you concerned about the appearance of your teeth and if so, what would you like to see changed? specify:
14.Would you rate your current dental health as:
Excellent
Good
Fair
Poor
15.Is your sugar intake:
High
Medium
Low
16.Brushing:
Vigorous
Light
How Often
17.Cleaning aids presently used:
Floss
Stimudents
Toothpick
Other
18. Do you have any emotional concerns regarding you dental visit
Fear
Time
Money
Embarrassment
Pain
19. Do you have any other concerns?
Medical History
Stroke
Heart murmur/problems
Stomach/Intestinal problems
Joint replacement
Mental/Nervous disorder
High/Low Blood pressure
Lung Disease
Hyper (hypo) glycemia
Rheumatic Fever
Drug Addiction
Epilepsy/Seizures
Hepatitis A, B, C.
Cold Sores
Cold Sores
Cold Sores
Liver Disease
Diabetes
Kidney Disease
Thyroid Disease
Asthma
1. Are you presently under the care of a physician?Yes No
2. Have you had a medical examination in the last 2 years? Yes No
3. Have you been hospitalized for any major condition?Yes No
4. Do you use any prescription or non-prescription drugs? Yes No
Please List:
5. Have you been warned against taking any medication?Yes No Please List and Describe:
6. Do you have any allergies?Yes No
7. Have you had any radiation or chemotherapy treatment ?Yes No
8. Have you had any injury or surgery to your face or jaw ?Yes No Additional Information:
9. Do you have frequent / severe headaches?Yes No Additional Information:
10. Do you have frequent earaches or hearing difficulties? Yes No
11. Has any member of your family had diabetes?Yes No
12. Do you bruise or bleed abnormally ?Yes No
12. Do you bruise or bleed abnormally ?Yes No
13. Do you ever experience shortness of breath or chest pain?Yes No
14. Are you on a special diet?Yes No
15. Have you ever fainted?Yes No
16. Do your ankles swell during the day?Yes No
17. Has your weight changed recently?Yes No
18. Do you have any disease, condition or problem not listed above? Yes No If yes, please describe:
19. Is there anything about yourself we should be made aware of? Yes No Explain: