Dental Health History Form

Name

Nombre

Apellido

Gender

Date of Birth

Patient Information

Reason for Visit

Welcome to our practice! What reason(s) are you here today?

Are you currently experiencing dental pain or discomfort?

Yes No

What is the date of your last dental visit with the hygienist? (Estimate if needed)

What is the date of your last dental x-rays? (Estimate if needed)

What is the name, city, and state of your previous dentist?

Rate your smile on a scale of 1 to 10, with 10 being completely satisfied:

If you feel your smile is less than ideal, how does this affect you?

I avoid smiling I avoid photos Low self-confidence I avoid social situations

How do you think having a wonderful smile would change your life? (Check all that apply)

More confidence Better career opportunities Improved relationships Feeling younger

What would you like to change about your smile? (Check all that apply)

Have you ever had any of the following in the last 3 years? (Check all that apply)

Cavity Root canal Tooth extraction Gum treatment Teeth whitening Orthodontic treatment

What are some of your habits or environmental conditions that may affect your mouth? (Check all that apply)

Do you have any other comments or concerns you would like to discuss?

Emergency Contact Information

Name

Nombre

Apellido

Phone Number

Do you have any of the following diseases or problems? If you check any of these items, report your condition to a member of the staff immediately.

Indicate Height and Weight

Women Only (Check all that apply)

Pregnant Nursing Taking birth control None of the above

How many weeks pregnant?

Date of Last Health Exam (Estimate if needed)

Purpose of the visit:

Are you in good health?

Yes No

Please provide details here

Has there been any change in your general health in the last year?

Yes No

Please provide details here

Have you had a serious illness, operation, or been hospitalized in the past 5 years?

Yes No

Please provide details here

Has a physician or previous dentist recommended that you take antibiotics prior to dental treatment?

Yes No

List antibiotics and the physicians name, specialty, and phone number.

Do you use controlled substances (drugs)?

Yes No

If you use tobacco (smoking, snuff, chew, bidis) how interested are you in stopping?

I don't use tobacco Not interested Somewhat interested Very interested

Do you drink alcoholic beverages?

Yes No

How many alcoholic drinks did you drink in the past 24 hours?

How many alcoholic drinks do you typically drink in a week?

Check all the medical conditions that apply to you:

Are you allergic to or have you had a reaction to: (Check all that apply)

If you have had joint replacement(s), indicate joint(s), date of surgery, and any complications here:

Have you ever been or are scheduled to be treated with any of these Bisphosphonate drugs? (Check all that apply)

List any over the counter and prescription drugs: (Name of Medication, Dosage, Frequency)

List any disease, condition, or problem not listed above that you think we should know about. Also use this space to further explain any condition above.

Patient Acknowledgment

Signature of Patient or Parent/Legal Guardian

Sign here

Date

Dental Health History Form

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