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

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
Women
Are you pregnant?
Yes
Month
No
 
Nursing?
Yes
Month
No
 
Taking birth control pills?
Yes
Month
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.

Signature
Date

When you click the Finish button, an email will be sent to you and the medical centre with a PDF of your consent.