Dental History Information For woman onlyAre you taking birth control pills?YesNoAre you nursing/breastfeeding?YesNoAre you pregnant?YesNoExpected delivery date Date Format: MM slash DD slash YYYY Is there a possibility of pregnancy?YesNoNOTE: 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 InformationDate of last dental visit?Name of your previous dentistDo you snore?YesNoDo you have problems with bad breath?YesNoReason for today's visit?Have you ever had an allergic reactions to a crown, metal filling or dental appliance?YesNoHave you ever had an oral cancer screening?YesNoHave you ever used an electric toothbrush?YesNoHow 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 highestAre your teeth sensitive to hot, cold or pressure?YesNoDo your gums bleed when you brush?YesNoHave you ever had complications from an extraction?YesNoAre you prone to frequent headaches?YesNoDo you grind or clench your teeth?YesNoDo you have sores, blisters or swelling on your gums lips or cheeks?YesNoHave you ever had orthodontic treatment?YesNoHave you ever had a popping or clicking near your ear when you chew?YesNoHave you or a family member ever been treated for periodontal disease?YesNoIf 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 Date Format: MM slash DD slash YYYY Email* Parent/GuardianDate Date Format: MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
