Dental / Medical History Form

Welcome! To help us provide the best possible care for your child, please complete both sides of this dental / medical history form. All information provided is completely confidential.

Your previous dentist’s name and contact

What are other dental aids you use? (Toothpick, Interplak, etc.)

Are any of your teeth sensitive to:

Hot/Cold ?
Yes No
Sweets?
Yes No
Biting / Chewing?
Yes No
Yes No
Do your gums bleed or hurt?
Do you frequently get cold sores, blisters, or any other oral lesions?
Do you have mouth odor or bad taste?
Have you ever experienced gum disease?
Have you noticed loose teeth or change in your bite?
Do you bite your lips or cheeks regularly?
Do you mouth breathe while awake/asleep?
Do you have tired jaws, especially in the morning?
Do you clench or grid your teeth while awake/asleep?
Do you smoke / chew tobacco?

Have you ever had

Yes No
Orthodontic treatment
Oral Surgery
Gum treatment
Your teeth adjusted or your bite adjusted
A night guard
Have you experienced?
Clicking or popping of jaw?
Pain? (joint, ear, side of face)
Difficulty of opening or closing your mouth?
Head, neck, or shoulder aches?
Are you satisfied with your teeth’s appearance?
Would you like to keep all your teeth?
Do you feel nervous about dental treatment?
If so, please describe
Have you ever had an upsetting dental experience?
If yes, please describe

Do you feel nervous about dental treatment? Yes No
Name and Contact of Physician
Have you taken any medication during the past two years? Yes No
Please name medications
Are you taking any medications now? Including regular dosages of aspirin? Yes No
If yes, please list name and dosage
Have you ever taken a medication for weight loss? Yes No
Are you aware of having allergic reaction to any medication or substance? Yes No
If yes, please list:
Have you ever been a patient in the hospital during the last five years? Yes No
List any hospitalizations, surgeries, serious illnesses

Are any of your teeth sensitive to:

Heart (surgery/disease) Yes No Ulcers Yes No Hepatitis Yes No
Chest pain Yes No Diabetes Yes No Venereal Disease Yes No
Heart murmur Yes No Thyroid Problem Yes No A.I.D.S Yes No
High Blood Pressure Yes No Glaucoma Yes No H.I.V. Positive Yes No
Mitral valve prolapse Yes No Contact Lenses Yes No Cold Sores/Fever Yes No
Artificial heart valve Yes No Emphysema Yes No Blood Transfusion Yes No
Pacemaker Yes No Tuberculosis Yes No Sickle Cell Disease Yes No
Rheumatic Fever Yes No Asthma Yes No Bruise Easily Yes No
Arthritis Yes No Arthritis Yes No Arthritis Yes No
Cortisone Medication Yes No Cortisone Medication Yes No Yellow Jaundice Yes No
Swollen Ankles Yes No Cortisone Swollen Ankles Yes No Neurological Disorder Yes No
Stroke Yes No Stroke Yes No Epilepsy Yes No
Diet (Special/Restricted) Yes No Diet (Special/Restricted) Yes No Fainting/Dizzy Spell Yes No
Artificial Joints Yes No Chemo Therapy Yes No Nervous / Anxious Yes No
Kidney Trouble Yes No Tumors Yes No Psychological Care Yes No
Do you use more than one pillow to sleep? Yes No
Have you lost or gained more than 10 lbs in the past year? Yes No
Do you have or have you had any disease, conditions, or problems not listed? Yes No
If so, please describe
Women Are you pregnant? Yes Month No
Nursing? Yes Month No
Taking birth control pills? Yes No

I understand the above information is necessary to provide my child with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask my respective health care provider or agency, which may release such information to you. I will notify the doctor of any change in my child’s health or medication.

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