DAVIS & ROBERTSON D.M.D P.S.C.

Health History
DAVIS & ROBERTSON D.M.D P.S.C.

Welcome! So that we may provide you with the best possible care please complete this medical dental history form. All information is completely confidential.
DENTAL HISTORY
Patient Name
Medical Alerts
What is the reason for your visit today?
Date of Last Dental Visit

MonthDayYear
Date
Last Dental Cleaning
Last Full Mouth X rays
What was done at your last dental visit?
Previous Dentist's Name
Address
How often do you have dental examinations?
How often do you brush your teeth?
How often do you floss?
What other dental aids do you use? (Interplak, toothpick, etc.)
Do you have any dental problems now?
If yes, please describe
Are any of your teeth sensitive to:
Hot or Cold?
Sweets?
Biting or Chewing?
Have you noticed any mouth odors or bad tastes?
Do you frequently get cold sores, blisters or any other oral lesions?
Do your gums bleed or hurt?
Have your parents experienced gum disease or tooth loss?
Have you noticed any loose teeth or change in your bite?
Does food tend to get caught in between your teeth?
Have you ever had instruction of the correct way to brush your teeth?
Do you:
Clench or grind your teeth while awake or asleep?
Bite your lips or cheeks regularly?
Hold foreign objects with your teeth? (pencils, pipe, pins, nails, fingernails)
Mouth breathe while awake or asleep?
Have tired jaws, especially in the morning?
Smoke/chew tobacco?
Have you ever had:
Orthodontic treatment?
Oral Surgery?
Periodontal treatment?
Your teeth ground or the bite adjusted?
A bite plate or mouth guard?
A serious injury to the mouth or head?
If so, please describe including cause:
Have you experienced:
Clicking or popping of the jaw?
Pain? (joint, ear, side of face)
Difficulty in opening or closing the mouth?
Difficulty in chewing on either side of the mouth?
Headaches, neckaches or shoulder aches?
Are you satisfied with your teeth's appearance?
Would you like to keep all your teeth all of your life?
Do you feel nervous about having dental treatment?
If so, what is your biggest concern?
Have you ever had an upsetting dental experience?
If yes, please describe:
Is there anything else about having dental treatment that you would like us to know?
If yes, please describe:
Health History
Are you experiencing any discomfort at this time?
If yes, please describe
Are you now under the care of a physician?
Physician's Name:
Physician's Address:
Date of last physical examination:
Are you in good health?
Have you been hospitalized, had a serious operation or illness within the past 5 years?
If so, what was the problem?
Do you have or have you had any of the following diseases or problems?

Other
Are you taking any medication(s), drugs, or pills; including non-prescription medicine(s)?
If yes, please list name and dosage:
Are you aware of having an allergic (or adverse reaction) to any medication or substance?
Please check any or all which apply:

Other
Do you use tobacco products?
If so, what types and amount:
Have you used tobacco products in the past?
Do you use alcohol?
Do you use cocaine, or other drugs?
Are you a recovering drug addict or alcoholic?
Do you have any disease, condition, or problem not listed on this form that you think I should know about?
If yes, please explain:
For Women Only
Are you pregnant, or you think you may be pregnant?
Are you nursing?
Are you taking birth control pills?
I UNDERSTAND ALL INFORMATION IS NECESSARY TO PROVIDE ME WITH DENTAL CARE IN A SAFE AND EFFICIENT MANNER, I HAVE ANSWERED ALL QUESTIONS TO THE BEST OF MY KNOWLEDGE. SHOULD FURTHER INFORMATION BE NEEDED, YOU HAVE MY PERMISSION TO ASK THE RESPECTIVE HEALTH CARE PROVIDER OR AGENCY, WHO MAY RELEASE INFORMATION TO YOU. I WILL NOTIFY THE DOCTOR OF ANY CHANGE IN MY HEALTH OR MEDICATION.
PATIENT/GUARDIAN SIGNATURE
DATE

MonthDayYear
Date
Should be Empty:

Health History

DAVIS & ROBERTSON D.M.D P.S.C.

DENTAL HISTORY

Do you:

Have you ever had:

Have you experienced:

Health History

For Women Only