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.
No
Yes
Speech problems/therapy?
No
Yes
Grind or clench teeth?
No
Yes
Oral habits (thumb/finger sucking, lip/nail biting)?
No
Yes
Injury to face, jaw, teeth or mouth?
No
Yes
Discomfort from teeth or gums?
No
Yes
Pain, tenderness or noise in either jaw?
No
Yes
Frequent headaches?
No
Yes
Teeth sensitive to hot or cold?
No
Yes
Previous periodontal (gum) treatment?
No
Yes
Abnormal swallowing (tongue thrust)?
No
Yes
Brush teeth daily?
No
Yes
Floss teeth daily?
No
Yes
Mouth breathing?
No
Yes
Snores during sleep?
No
Yes
Any missing or extra permanent teeth?
No
Yes
Apprehensive about dental care?
No
Yes
Periodontal (gum) problems?
No
Yes
Frequent canker sores or cold sores?
No
Yes
Problems with food trapped between teeth?
If any of the above dental questions were answered 'Yes', please explain:
TMJ History
No
Yes
Do you experience soreness in the muscles of your face or around your ears?
No
Yes
Do you have a history of jaw joint problems?
No
Yes
Have you been treated for "TMJ"?
No
Yes
Do you have difficulty chewing or opening your mouth?
No
Yes
Has your jaw ever locked?
No
Yes
Does your bite feel uncomfortable or unusual?
If any of the above TMJ questions were answered 'Yes', please explain:
Medical History
No
Yes
Does the patient need to premedicate prior to dental visit?
No
Yes
Has there been any change in the patient's general health within the last year?
No
Yes
Is the patient now under the care of a physician (other than routine)? If so, what is being treated?
No
Yes
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:
No
Yes
Latex
No
Yes
Penicillin or other antibiotics
No
Yes
Sulfa drugs
No
Yes
Aspirin, Ibuprofen, Tylenol
No
Yes
Local anesthetics
No
Yes
Codeine or other narcotics
No
Yes
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.
No
Yes
Liver Disease / Jaundice / Hepatitis
No
Yes
Kidney Disease
No
Yes
HIV/AIDS or other infectious disease
No
Yes
Tonsils/Adenoids Removed
No
Yes
Handicaps/Disabilities
No
Yes
Arthritis / Joint problems
No
Yes
Sinus trouble
No
Yes
Heart Problems
No
Yes
Blood Conditions
No
Yes
Diabetes
No
Yes
Growth Problems
No
Yes
Cancer
No
Yes
Received Radiation Treatment
No
Yes
Thyroid / Endocrine Problems
No
Yes
Stomach ulcer
No
Yes
Hormone Therapy
No
Yes
Metal Allergy
No
Yes
Nervous Disorders
No
Yes
Bone Disorders/Bone Loss
No
Yes
Seizures / Epilepsy / Neurological Disease
No
Yes
Asthma
No
Yes
Respiratory problems / Emphysema
No
Yes
History of anorexia or bulemia
No
Yes
FEMALES: Are you pregnant
No
Yes
Take Bisphosphonates (Fosamax, Boniva)
If any of the above medical questions were answered 'Yes' , please explain:
I certify that I have read and understand the above. I acknowledge that I have completed this form to the best of my knowledge, and that my questions have been answered to my satisfaction. I will not hold my orthodontist or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. If there is any change later to this history record or medical or dental status, I will inform the practice.