Patient Name

First Name Last Name

Dental Questionnaire

	Yes	No
Do you get food caught between your teeth?
Do you have any missing teeth?
Do your gums bleed?
Do you have areas of receded gums?
Do you floss regularly?
Does gum disease run in your family?
Are your teeth hot/cold sensitive?
Teeth extracted?
Are your teeth sensitive to sweets?
Do you clench or grind your teeth?
Do you have a night guard/bite splint?
Have you ever had an oral surgery?
Do you have tired jaws?
Do you have orthodontics/braces?
Do you have popping or clicking in the jaw?
Have you ever had a periodontal treatment?
Do you chew on pens, fingernails, etc?
Have you had any injury to your face/jaw?
Do you drink coffee, tea or red wine?

Previous Dentist Name

First Name Last Name

Last Visit

Date

Last Cleaning

Date

Medical Questionnaire

	Yes	No
Heart surgery, disease, attack?
Blood transfusion?
Heart murmur?
Hemophilia or blood disorder?
Mitral valve prolapse?
Hepatitis A, B?
Heart attack or strokes?
Tuberculosis or lung disease?
Artificial heart valve?
Tumors?
Heart pacemaker?
Headaches or migraines?
Artificial joints (hip, knee, etc)?
Convulsions or epilepsy?
Neurological disorders?
Dizzy spells or fainting?
Rheumatic fever?
Cold sores or fever blisters?
Diabetes?
Thyroid disorder?
Kidney disease?
Stomach, intestinal, or colon disorders?
Jaundice or liver disease?
Cortisone or steroid therapy?
High blood pressure?
Possess the HIV or AIDS antibody?
Low blood pressure?
Psychiatric or psychological care?
Cancer?
Hay fever or airborne allergies?
Radiation or Chemotherapy?
Bruise easily?
Emphysema or asthma?
Venereal disease?

Do you have any other disease/condition not listed above?

Do you use recreational drugs?

Yes No

How often do you consume alcoholic beverages?

Do you or have you ever smoked or used tobacco? Please describe type, frequency and duration

Are you currently pregnant or trying to become pregnant?

Yes No

Are you currently use a prescription type contraceptive? Please explain

I, the above-named patient, understand the above 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. Dental care has my permission to ask the respective health care provider or agency, who may release such information. I will notify this dental care facility of any and all changes in my health or medications. I consent to the performing of dental procedures agreed to be necessary or advisable, including the use of local anesthetics.

Signature
Date

Dental History