Welcome to Our Dental Office! Medical/Dental History Update
Periodontal History
Are you aware of bad breath or a bad taste in your mouth? Yes No
Does food routinely get wedged between your teeth? Yes No
Does your mouth tend to be dry? Yes No
Are your parents or siblings missing any of their natural teeth? Yes No
Habits
Do you smoke cigars or cigarettes? Recreational smoking? (circle all that apply) If so, how many?
Do you chew on pencils, gum, ice cubes, or popcorn kernels? Etc.(circle all that apply) Yes No
Do you bite your fingernails, pins, or use a pipe? Etc. (circle all that apply) Yes No
Do you drink coffee, tea, or cola drinks? (circle all that apply) Yes No
How often?
Do you bite your lips or cheeks regularly? Yes No
Do you breathe through your mouth when awake or asleep? Yes No
Do you snore during sleep? Yes No
Do you participate in any sports? Yes No
If so, what kind?
Aesthetics
Are you satisfied with the appearance of your teeth and smile? Yes No
Would you be interested in knowing more about veneers, bonding, tooth whitening, implants, other cosmetic options? Yes No
If you could wave a magic wand, what would you change about your smile?
Medical History
Are you in good health
Yes No
When was your last complete medical examination? Select Date
Have you ever been hospitalized for a serious illness or operation? Yes No
If so, Please explain
Are you currently taking any prescription or non-prescription medication? Yes No
If yes, please list
Do you have any allergies? Including: Medications, foods, latex, environmental, other? Yes No
If yes, please list
Have you ever had a previous reaction to metal or metal jewellery? Yes No
Have you ever had an adverse reaction to dental freezing, general anaesthetic, penicillin, codeine, aspirin, or other drugs? Yes No
If yes, what kind of reaction?
Do you suffer from canker sores or cold sores? Yes No
Are you subject to prolonged bleeding, and/or do you bruise easily? Yes No
Have you ever fainted? Yes No
What were the circumstances?
Have you ever experienced any recent unexplained weight change, or increased thirst, appetite, or frequency of urination? Yes No
Have you ever had a shortness of breath or pains in your chest? Yes No
Have you had or ever been treated for rheumatic fever, rheumatic, or congenital heart disease? Yes No
Do you have a heart condition of any kind? (angina pectoris, arrhythmias, or previous heart attack – please circle) Yes No
Has your physician ever told you that you have a heart murmur or mitral valve prolapse? Yes No
Have you had any organ transplants or joint replacements? Yes No
If Yes, When
Do you have a prosthetic heart valve or wear a pacemake? Yes No
Have you been told by your medical doctor that you need to take antibiotics before dental treatment? Yes No
Have you ever been treated for Hepatitis? Yes No
Which Type
Do you have or have you had any of the following diseases or conditions? (please circle all that apply) Yes No
Are you on any special diet? (e.g. salt restricted diet) Yes No
Do you wear contact lenses? Yes No
On a scale of 1 to 5, please rate your current dental health: Excellent 1 2 3 4 5 Very Poor
What priority do you place on your dental health? Highest Priority 1 2 3 4 5 Lowest Priority
I, the undersigned, certify that all of the above medical and dental information is true to the best of my knowledge and I have not omitted any pertinent information. Should the need arise, I allow my medical doctor to be consulted. I understand that I am financially responsible to the dentist for all necessary treatment.
