aware of a change in your health in the last 24
hours (e.g., fever, chills, new cough, or[ diarrhea)
49.
taking medication for weight management
50.
taking dietary supplements
51.
often exhausted or fatigued
52.
experiencing frequent headaches
53.
a smoker, smoked previously or use smokeless
tobacco
54.
considered a touchy/sensitive person
55.
often unhappy or depressed
56.
taking birth control pills
57.
currently pregnant
58.
diagnosed with a prostate disorder
Describe any current medical treatment, impending surgery,
genetic/development delay, or other treatment that may possibly affect
your dental treatment. (i.e. Botox, Collagen Injections)
List all medications, supplements, and or vitamins taken within the last two
years.
Drug
Purpose
PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY
MEDICATIONS YOU MAY BE TAKING.
Emergency Contact
Excellent
Good
Fair
Poor
3 mo.
4 mo.
6 mo.
12 mo.
Not routinely
Personal History
Yes
NO
No to
All
1.
Are you fearful of dental treatment? How fearful?
2.
Have you had an unfavorable dental experience?
3.
Have you ever had complications from past dental treatment?
4.
Have you ever had trouble getting numb or had any reactions to local anesthetic?
5.
Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
6.
Have you had any teeth removed or missing teeth that never developed or lost teeth due to injury or facial trauma?
Gum And Bone
Yes
NO
No to
All
7.
Do your gums bleed or are they painful when brushing or flossing?
8.
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
9.
Have you ever noticed an unpleasant taste or odor in your mouth?
10.
Is there anyone with a history of periodontal disease in your family?
11.
Have you ever experienced gum recession?
12.
Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
13.
Have you experienced a burning or painful sensation in your mouth not related to your teeth?
Tooth Structure
Yes
NO
No to
All
14.
Have you had any cavities within the past 3 years?
15.
Does the amout of saliva in your mouth seem too little or do you have difficulty swallowing any food?
16.
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
17.
Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?
18.
Do you have grooves or notches on your teeth near the gum line?
19.
Have you ever broken teeth, chipped teeth, or had toothache or cracked filling?
20.
Do you frequently get food caught between any teeth?
Bite And Jaw Joint
Yes
NO
No to
All
21.
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
22.
Do you feel like your lower jaw is being pushed back when you bite your back teeth together?
23.
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
24.
In the past 5 years, have your teeth changed (become shorter, thinner or worn) or has your bite changed?
25.
Are your teeth becoming more crooked, crowded, or overlapped?
26.
Are your teeth developing spaces or becoming more loose?
27.
Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
28.
Do you place your tongue between your teeth or close your teeth against your tongue?
29.
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
30.
Do you clench or grind your teeth together in the daytime or make them sore?
31.
Do you have any problems with sleep (i.e. restlessness or teeth grindling), wake up with a headache or an awareness of your teeth?
32.
Do you wear or have you ever worn a bite appliance?
Smile Characteristics
Yes
NO
No to
All
33.
Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?
34.
Have you ever whitened (bleached) your teeth?
35.
Have you felt uncomfortable or self conscious about the appearance of your teeth?
36.
Have you been disappointed with the appearance of previous dental work?
*I certify that the above information is complete and accurate.
