Health History
Name (First) (MI) (Last) :
Dental Information
If your answer to any of the following questions is YES, then check the box under YES. If your answer is NO, leave blank. If you do not know, select the option under DK. |
Yes |
No |
DK |
| 1. Do your gums bleed when you brush or floss? |
1 |
| 2. Are your teeth sensitive to cold, hot, sweets or pressure? |
2 |
| 3. Is your mouth dry? |
3 |
| 4. Have you had any periodontal (gum) treatments? |
4 |
| 5. Have you ever had orthodontic (braces) treatment? |
5 |
| 6. Have you had any problems associated with previous dental treatment? |
6 |
| 7. Is your home water supply fluoridated? |
7 |
| 8. Do you drink bottled or filtered water? |
8 |
| 9. If yes, how often? |
9 |
| 10. Are you currently experiencing dental pain or discomfort? |
10 |
| 11. Do you have earaches or neck pains? |
11 |
| 12. Do you have any clicking, popping or discomfort in the jaw? |
12 |
| 13. Do you brux or grind your teeth? |
13 |
| 14. Do you have sores or ulcers in your mouth? |
14 |
| 15. Do you wear dentures or partials? |
15 |
| 16. Do you participate in active recreational activities? |
16 |
| 17. Have you ever had a serious injury to your head or mouth? |
17 |
| 18. Date of your last dental exam: |
18 |
| 19. What was done at that time? |
19 |
| 20. Date of last dental x-rays: |
20 |
| 21. What is the reason for you dental visit today? |
|
|
21 |
| 22. How do you feel about your smile? |
|
|
22 |
| |
|
| Medical Information |
Yes |
No |
DK |
| 1. Are you now under the care of a physician? |
1 |
| Physician Name:
Phone:
|
| Address:
State:
ZIP:
|
| 2. Are you in good health? |
2 |
| 3. Has there been any change in your general health within the past year? |
3 |
| 4. If Yes, what condition is being treated? |
4 |
| 5. Date of last physical exam: |
5 |
| 6. Have you had a serious illness, operation, or been hospitalized in the past 5 years? |
6 |
| 7. If yes, what was the illness or problem? |
7 |
| 8. Are you taking or have you recently taken any prescription or over the counter medicine(s)? |
8 |
| 9. If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements: |
9 |
| 10. Do you wear contact lenses? |
10 |
| 11. Are you taking, or have you taken, any diet drugs such as Pondimin (fenflluramine), Redux (dexphenfluramine) or phen-fen ( fenflluramine - phentermine combination) ? |
11 |
| 12. Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax) or risedronate (Actonel) for osteoporosis or Paget's disease? |
12 |
| 13. Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Panget's disease. multiple myeloma or metastatic cancer? |
13 |
| 14. Date Treatment began: |
14 |
| 15. Do you use controlled substances (drugs)? |
15 |
| 16. Do you use tobacco (smoking, snuff, chew, bidis)? |
16 |
| 17. If so, how interested are you in stopping? |
|
| 18. Do you drink alcoholic beverages? |
18 |
| 19. If so, how much alcohol did you drink in the last 24 hours? |
19 |
| 20. If yes, how much do you typically drink in a week? |
20 |
| 21. Are you pregnant? |
21 |
| 22. If so, number of weeks: |
22 |
| 23. Taking birth control pills or hormonal replacement? |
23 |
| 24. Nursing? |
24 |
| |
