Dental History     
*Patient First Name: *Last Name:
Please select YES if the patient has had any of the conditions listed below either now or in the past.
Speech problems/therapy?
Grind or clench teeth?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Pain, tenderness or noise in either jaw?
Frequent headaches?
Teeth sensitive to hot or cold?
Previous periodontal (gum) treatment?
Abnormal swallowing (tongue thrust)?
Brush teeth daily?
Floss teeth daily?
Mouth breathing?
Snores during sleep?
Sleep apnea?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Periodontal (gum) problems?
Frequent canker sores or cold sores?
Problems with food trapped between teeth?
If any of the above dental questions were answered 'Yes', please explain:
   TMJ History     
Do you experience soreness in the muscles of your face or around your ears?
Do you have a history of jaw joint problems?
Have you been treated for "TMJ"? Do you have difficulty chewing or opening your mouth?  
Has your jaw ever locked?
Does your bite feel uncomfortable or unusual?
If any of the above TMJ questions were answered 'Yes', please explain:
   Medical History     
   Does the patient need to premedicate prior to dental visit?
   Has there been any change in the patient's general health within the last year?
   Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
   Has the patient had a serious illness/hospitalization in the past 5 years? If so, what for?
List any medications currently being taken by the patient (include non-prescirption):
Allergies or drug reaction to:
Latex Penicillin or other antibiotics
Sulfa drugs Aspirin, Ibuprofen, Tylenol
Local anesthetics Codeine or other narcotics  
Other:
List any drug allergies or sensitivities (not listed above) that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past.
Liver Disease / Jaundice / Hepatitis
Kidney Disease
HIV/AIDS or other infectious disease
Tonsils/Adenoids Removed
Handicaps/Disabilities
Arthritis / Joint problems
Sinus trouble
Heart Problems
Blood Conditions
Diabetes
Growth Problems
Cancer
Received Radiation Treatment
Thyroid / Endocrine Problems
Stomach ulcer
Hormone Therapy
Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Seizures / Epilepsy / Neurological Disease
Asthma
Respiratory problems / Emphysema
History of anorexia or bulemia
FEMALES: Are you pregnant
Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain: