Primary reason for this dental appointment: Examination   Emergency   Consultation

Dental History

Do you have a specific dental problem?	Yes   No
Do you have dental examinations on a regular basis?	Yes   No
Do you think you have active decay or gum disease?	Yes   No
Do you brush and floss on a routine basis?	Yes   No
Do your gums ever bleed?	Yes   No
Do you like your smile?	Yes   No
Does food catch between your teeth?	Yes   No
Any loose teeth?	Yes   No
Do you want to keep your remaining teeth?	Yes   No
Do you ever have clicking, popping or discomfort in the jaw joint?	Yes   No
Do you brux or grind?	Yes   No
Have your past experiences in a dental office always been positive?	Yes   No
Do you smoke or chew?	Yes   No
Any sores or growths in your mouth?	Yes   No

Medical History

Are you under a physician’s care now?	Yes   No
Have you ever been hospitalized or had a major operation?	Yes   No
Have you ever had a serious injury to your head or neck?	Yes   No
Are you taking any medications, aspirin, vitamins, herbals, pills or drugs?	Yes   No
Are you on a special diet?	Yes   No

Are you allergic to any medications or substances? Please check all that apply.
Aspirin   Penicillin   Codeine   Acrylic   Metal   Latex   Rubber   Milk  

Women, please check any of the following that apply to you.
Pregnant/trying to get pregnant Nursing Taking oral contraceptives

Do you now have or have ever had any of the following medical conditions? Do you take any of these medicines? Please check any that apply.
*If yes, please call prior to your appointment. Premedication or changes in medication may be required.

Have you ever had any other serious illness not checked above?	Yes   No
Do you wish to talk to the dentist privately about any problems?	Yes   No

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