Medical & Dental History Continued Yes No
25. Gastrointestinal (GI) Disorder (hepatitis, acid reux, Crohn’s, etc.)
q q
26. Musculoskeletal/Connective tissue disorder (arthritis, osteoporosis, bromyalgia, etc.)
q q
27. Growth/Development problem (developmental delay, learning disability, behavioral problems,
etc.)
q q
28. Infectious disease (HIV/AIDS, MRSA, cold sores, STDs, etc.)
q q
29. Head/Eye/Ear/Nose/Throat problem (glaucoma, cataract, hearing impairment, etc.
q q
30. Eating disorder (anorexia, bulimia, etc.)
q q
31. Immunosuppression (compromised immune system)
q q
32. Are all immunizations/vaccinations up to date?
q q
33. Do you have any other problem, disease or condition not listed?
q q
34. Are you allergic to or have you had a reaction to any substance or medication?
q q
List all substances/medications you are allergic to: Reaction:
Dental History
1. Chief Complaint?
2. Date of your last dental visit: 3. What was done at that time?
4. Date of your last dental x-rays: 5. Date of your last dental cleaning:
6. Are you currently experiencing any dental pain or discomfort?
q q
7. Are your teeth sensitive to cold, hot, sweets or pressure?
q q
8. Do you have swelling in or around your mouth, face or neck?
q q
9. Do you have loose teeth?
q q
10. Do you have bad breath, metallic taste or unpleasant taste?
q q
11. Do you have any clicking, popping or discomfort in your jaw?
q q
12. Do you clench, brux or grind your teeth?
q q
13. Do you have sores, ulcers or tumors in your mouth?
q q
14. Have you had any periodontal treatments? (deep cleaning/gum surgery)
q q
15. Have you ever had orthodontic treatment? (braces, retainers)
q q
16. Have you ever had local anesthetic (numbing) for dental purposes?
q q
If yes, have you experienced any problems?
q q
17. Have you had problems associated with previous dental treatment?
q q
18. How often do you brush your teeth?
q Never q Sometimes q Once a day
q Twice a day q More than twice a day
19. How often do you oss your teeth?
q Never q Sometimes q Once a day
q Twice a day q More than twice a day
20. Do your gums bleed when you brush or oss?
q Never q Sometimes q Always
21. Do you have any obstacles to cleaning or caring for your teeth?
q q
22. Rate your fear of dental treatment on a scale of 0 (no fear) to 10 (extreme fear):
0 1 2 3 4 5 6 7 8 9 10
23. How often do you need to have someone help you when you read instructions, pamphlets, or other
written material from your doctor or pharmacy?
q Never q Rarely q Sometimes q Often q Always
24. Do you have any previous or present activities or behaviors that may place you at risk for
facial injury?
q q
