Patient Information
Date of Birth:
I certify that I have answered the following questions to the best of my knowledge. I have asked the doctor or staff to explain any items I did not understand and they have answered my questions to my satisfaction. I will not hold the doctor or his staff responsible for any errors or omissions that I may have made in completion of this form.
In the event my account becomes delinquent. I understand I am responsible for payment of actual and reasonable collection charges and/or attorney fees.
Medical History
Good dental health is the result of a working partnership between you, your dentist, and your dental hygienist. We ask the questions on the following pages because the answers will allow us to treat you on more individual basis and provide the care appropriate for your particular needs. Considered and correct answers will greatly assist us in providing the best quality in dental care. Your answers and all information above are for our records only and will be considered confidential.
  1. How would you rate your general health?
  2. Typically, how many times each year to you get sick?
  3. Has there been any change in your general heatlh within the past year? YesNo
  4. My last physical examination was on:
  5. Are you now under the care of a physician? YesNo
  6. Have you been hospitalized or had a serious illness within the past five years?: YesNo
  7. Are you currently taking any medications (including over-the-counter)? YesNo
  8. Are you allergic to or have you reacted adversely to any medications? YesNo
  9. Are you allergic to or have you reacted adversely to any metals? (e.g., do you break out when wearing certain kinds of jewelry?) YesNo
  10. Have you ever had any kind of substance abuse problem? YesNo
  11. Do you or have you had any of the following diseases or problems?
    Damaged heart valves or artificial heart valves, heart murmur
    Cardiovascular disease (heart trouble, heart attack, angina, coronary insufficiency, stroke)
    Allergy - asthma or hayfever
    Venereal disease
    High or low blood pressure
    Stomach ulcers
    Fainting spells or seizures
    Kidney trouble
    Psychiatric problems
    Arthritis or Inflammatory Rheumatism
    Hepatitis, Jaundice or liver disease
    Sinus trouble
    AIDS or other immunosuppressive disorders
    Have you ever had a blood transfusion? YesNo
    If yes, when?
    Hav eyou been tested for HIV since then? YesNo
  12. Women:
    Are you pregnant? YesNo
    Are you nursing? YesNo
  13. Do you have any disease, condition or problem not listed above that you think I should know about? YesNo
Dental History
  1. Are you having any discomfort at this time? YesNo
  2. Have you ever had any serious trouble associated with previous dentistry? YesNo
  3. Date of last dental visit:
  4. When was the last time your teeth were professionally cleaned (scaled and polished)?:
  5. How often do you usually have a recare visit with a hygienist?
  6. Periodontal
    Do your gums ever bleed? YesNo
    Do your gums ever become tender/red/swollen? YesNo
    Do you have unpleasant taste in your mouth and/or bad breath? YesNo
    Do you have burning tongue/lips? YesNo
    Do you have frequent blisters on lips or in mouth? YesNo
    Do you bite your cheeks or lips? YesNo
    Do you have swelling/lumps in mouth? YesNo
    Have you ever been told you have periodontal disease (gum disease, pyorrhea, trench mouth)? YesNo
    If gum disease was diagnosed, was any treatment done at the time? YesNo
    If yes, please complete the following:
    Have you ever undergone treatment for gum disease more than once? YesNo
    Have you lost any teeth because of gum disease? YesNo
    Have any members of your family ever undergone treatment for gum disease? YesNo
    How often did you see the dentist/hygienist after treatment was completed? Once every months.
    Are any of your teeth loose? YesNo
    Are any of your teeth sensitive to hot or cold? YesNo
    Are any of your teeth sensitive to sweets YesNo
    Do any of your teeth hurt when you bite down? YesNo
    Is "food wedging" a problem when you chew? YesNo
    Did you ever wear braces? YesNo
    Dental Habits
    Please note how often you use the following:
    Dental Floss
    Oral Rinse
    Other (e.g., WaterPik, ViaJet, etc.):
  7. Please choose one answer for each of the following:
Lifestyle Questionnaire
When we take good care of our health, our immune systems are not over-taxed. In general, a healthy lifestyle creates a healthy immune system. A healthy immune system contributes to better resistance, fewer episodes of infection, and more rapid healing.
We ask these questions to help predict how you might respond to any treatment and to alert us to any potential problems.

Is your diet well-balanced? YesNo
Do you take regular vitamin/mineral supplements? YesNo
Are you aware of any hormonal imbalances? YesNo
Have you ever been told you are "borderline diabetic"? YesNo
Do you smoke or chew tobacco? YesNo
If no, have you ever smoked or chewed tobacco? YesNo
For how long Years
How many years ago did you quit?
Do you drink alcohol? YesNo
Have you been under an unusual amount of stress lately? YesNo
How many hours per week do you work?
Do you exercise regularly? YesNo
How often per week?
Are there any aspects of your lifestyle that you would like to discuss with the dentist or hygienist? YesNo
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