Dental History Information For woman only Are you taking birth control pills? Yes No Are you nursing/breastfeeding? Yes No Are you pregnant? Yes No Expected delivery date MM slash DD slash YYYY Is there a possibility of pregnancy? Yes No NOTE: Antibiotics (such as penicillin) may alter the effect of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control. Dental History Information Date of last dental visit? Name of your previous dentist Do you snore? Yes No Do you have problems with bad breath? Yes No Reason for today's visit? Have you ever had an allergic reactions to a crown, metal filling or dental appliance? Yes No Have you ever had an oral cancer screening? Yes No Have you ever used an electric toothbrush? Yes No How often do you floss your teeth? How important is your dental health to you? On a scale from 1 to 10, with 10 being the highest Are your teeth sensitive to hot, cold or pressure? Yes No Do your gums bleed when you brush? Yes No Have you ever had complications from an extraction? Yes No Are you prone to frequent headaches? Yes No Do you grind or clench your teeth? Yes No Do you have sores, blisters or swelling on your gums lips or cheeks? Yes No Have you ever had orthodontic treatment? Yes No Have you ever had a popping or clicking near your ear when you chew? Yes No Have you or a family member ever been treated for periodontal disease? Yes No If you could change something about your smile what would it be: Whiter Straighter Close space Replace black mercury filling with tooth colored restorations Repair chipped teeth Replace missing teeth Less gums showing Replace old crowns or caps that don't match I certify that I have read and understand the questions, above. I acknowledge that my questions have been answered to my satisfaction. I will not hold my dentist or any other members of his/her staff responsible for any errors that I have made in the completion of this form. Adult/Guardian: I hereby consent to the treatment indicated on my examination form, including the use of any anesthetics, sedatives, or x-rays, as may be deemed necessary by the doctor. Patient* Date MM slash DD slash YYYY Email* Parent/Guardian Date MM slash DD slash YYYY Name This field is for validation purposes and should be left unchanged. Δ
