Dental History This form works best with JavaScript enabled. About You Let’s start with the basics. Fields marked * are required. Full name * How do you wish to be addressed? Date of birth * Cell phone * Email * Home phone Street address * City * State * ZIP * Work & Family Your employment Place of employment Present position Employer address Employer phone Family Marital status—Please choose an option—MarriedSingleChildOther Spouse’s name Spouse’s place of employment Spouse’s present position Spouse’s employer address Spouse’s employer phone Your Visit Emergency contact name * Emergency contact phone * Purpose of this visit * Preferred pharmacy Whom may we thank for this referral? Other family members in our practice Privacy & Messages HIPAA release: tell us who may receive your information and how to reach you. Release of information *I authorize the release of my diagnosis, records, examinations and claims information to the people listed belowInformation is not released to anyone Spouse (name) Children (names) Other (name) This release remains in effect until you terminate it in writing. Please callMy homeMy workMy cell If we can’t reach you *You may leave a detailed messagePlease leave a message asking me to return your callOther (explain below) Other message instructions Best day(s) to reach you Best time Health Overview Physician name & specialty Most recent physical exam Purpose of that exam Your general health *ExcellentGoodFairPoor Have you ever had… 1. Hospitalization for illness or injuryYesNo Mark any unanswered as “No” Hospitalization details 2. Allergies or bad reactions (check all that apply)Aspirin, ibuprofen, acetaminophen, codeinePenicillinErythromycinTetracyclineSulfaLocal anestheticFluorideChlorhexidine (CHX)IodineMetals (nickel, gold, silver, etc.)LatexNutsFruitMilkRed dyeOther Allergy details (reaction, “other” allergies) Medical History: Part 1 Do you have, or have you ever had… 3. Heart problems, or cardiac stent within the last six monthsYesNo 4. History of infective endocarditisYesNo 5. Artificial heart valve, repaired heart defect (PFO)YesNo 6. Pacemaker or implantable defibrillatorYesNo 7. Orthopedic or soft tissue implant (e.g. joint replacement, breast implant)YesNo 8. Heart murmur, rheumatic or scarlet feverYesNo 9. High or low blood pressureYesNo 10. A stroke (taking blood thinners)YesNo 11. Anemia or other blood disorderYesNo 12. Prolonged bleeding due to a slight cut (or INR > 3.5)YesNo 13. Pneumonia, emphysema, shortness of breath, sarcoidosisYesNo 14. Chronic ear infections, tuberculosis, measles, chicken poxYesNo 15. Breathing problems (e.g. asthma, stuffy nose, sinus congestion)YesNo 16. Sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)YesNo 17. Kidney diseaseYesNo 18. Liver disease or jaundiceYesNo 19. Vertigo (e.g. “the room is spinning”)YesNo 20. Thyroid, parathyroid disease, or calcium deficiencyYesNo 21. Hormone deficiency or imbalance (e.g. polycystic ovarian syndrome)YesNo 22. High cholesterol or taking statin drugsYesNo 23. Diabetes (include HbA1c if known)YesNo 24. Stomach or duodenal ulcerYesNo 25. Digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia, anorexia)YesNo Mark any unanswered as “No” Please explain any “Yes” answers Medical History: Part 2 Do you have, or have you ever had… 26. Osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates)YesNo 27. Arthritis or goutYesNo 28. Autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)YesNo 29. GlaucomaYesNo 30. Contact lensesYesNo 31. Head or neck injuriesYesNo 32. Epilepsy, convulsions (seizures)YesNo 33. Neurologic disorders (e.g. Alzheimer’s disease, dementia, prion disease)YesNo 34. Viral infections and cold soresYesNo 35. Any lumps or swelling in the mouthYesNo 36. Hives, skin rash, hay feverYesNo 37. STI/STD/HPVYesNo 38. Hepatitis (include type)YesNo 39. HIV/AIDSYesNo 40. Tumor, abnormal growthYesNo 41. Radiation therapyYesNo 42. Chemotherapy, immunosuppressive medicationYesNo 43. Emotional difficultiesYesNo 44. Psychiatric treatment or antidepressant medicationYesNo 45. Concentration problems or ADD/ADHDYesNo 46. Alcohol/recreational drug useYesNo Mark any unanswered as “No” Please explain any “Yes” answers Current Health Are you… 47. Presently being treated for any other illnessYesNo 48. Aware of a change in your health in the last 24 hours (e.g. fever, chills, new cough, or diarrhea)YesNo 49. Taking medication for weight managementYesNo 50. Taking dietary supplements, vitamins, and/or probioticsYesNo 51. Often exhausted or fatiguedYesNo 52. Experiencing frequent headaches or chronic painYesNo 53. A smoker, smoked previously or other (e.g. smokeless tobacco, vaping, e-cigarettes, and cannabis)YesNo 54. Considered a touchy/sensitive personYesNo 55. Often unhappy or depressedYesNo 56. Taking birth control pillsYesNo 57. Currently pregnantYesNo 58. Diagnosed with a prostate disorderYesNo Mark any unanswered as “No” Please explain any “Yes” answers Current medical treatment, impending surgery, genetic/developmental delay, or other treatment that may affect dental care (e.g. Botox, collagen injections) Medications, supplements, vitamins and/or probiotics taken in the last two years (drug and purpose) Dental Background Previous dentist Condition of your mouth *ExcellentGoodFairPoor Most recent dental exam Most recent x-rays Most recent treatment (other than cleaning) I routinely see my dentist every *3 months4 months6 months12 monthsNot routinely What is your immediate concern? * Dental History: Part 1 Personal history How fearful are you of dental treatment? (1 = least, 10 = most) 1. Are you fearful of dental treatment?YesNo 2. Have you had an unfavorable dental experience?YesNo 3. Have you ever had complications from past dental treatment?YesNo 4. Have you ever had trouble getting numb or had any reactions to local anesthetic?YesNo 5. Did you ever have braces, orthodontic treatment or had your bite adjusted? (Add age below)YesNo 6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?YesNo Mark any unanswered as “No” Please explain any “Yes” answers Gum and bone 7. Do your gums bleed sometimes or are they ever painful when brushing or flossing?YesNo 8. Have you ever been treated for gum disease, had scaling and root planing, or been told you have lost bone around your teeth?YesNo 9. Have you ever noticed an unpleasant taste or odor in your mouth?YesNo 10. Is there anyone with a history of periodontal disease in your family?YesNo 11. Have you ever experienced gum recession, or can you see more of the roots of your teeth?YesNo 12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?YesNo 13. Have you experienced a burning or painful sensation in your mouth not related to your teeth?YesNo Mark any unanswered as “No” Please explain any “Yes” answers Dental History: Part 2 Tooth structure 14. Have you had any cavities within the past 3 years?YesNo 15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?YesNo 16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?YesNo 17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?YesNo 18. Do you have grooves or notches on your teeth near the gum line?YesNo 19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?YesNo 20. Do you frequently get food caught between any teeth?YesNo Mark any unanswered as “No” Please explain any “Yes” answers Bite and jaw joint 21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)YesNo 22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?YesNo 23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?YesNo 24. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?YesNo 25. Are your teeth becoming more crooked, crowded, or overlapped?YesNo 26. Are your teeth developing spaces or becoming looser?YesNo 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?YesNo 28. Do you place your tongue between your teeth or close your teeth against your tongue?YesNo 29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?YesNo 30. Do you clench or grind your teeth together in the daytime or make them sore?YesNo 31. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?YesNo 32. Do you wear or have you ever worn a bite appliance?YesNo Mark any unanswered as “No” Please explain any “Yes” answers Smile characteristics 33. Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size, display)?YesNo 34. Have you ever bleached (whitened) your teeth?YesNo 35. Have you felt uncomfortable or self-conscious about the appearance of your teeth?YesNo 36. Have you been disappointed with the appearance of previous dental work?YesNo Mark any unanswered as “No” Please explain any “Yes” answers Review & Sign Almost done. Please read and sign below. I hereby give consent to the team of Fleetwood Dental, P.C. to perform whatever dental treatment is deemed reasonably necessary.I will advise Fleetwood Dental of any change in my medical history or the medications I am taking.I authorize the HIPAA information release and message preferences I selected in this form. This release remains in effect until terminated by me in writing. I have read and agree to the statements above, and the information I provided is accurate to the best of my knowledge. Signature: type your full legal name *Typing your name acts as your electronic signature. BackContinue
