DAVIS & ROBERTSON D.M.D P.S.C.

Health History
DAVIS & ROBERTSON D.M.D P.S.C.

Welcome! So that we may provide you with the best possible care please complete this medical dental history form. All information is completely confidential.
DENTAL HISTORY
Patient Name
Medical Alerts
What is the reason for your visit today?
Date of Last Dental Visit

MonthDayYear
Date
Last Dental Cleaning
Last Full Mouth X rays
What was done at your last dental visit?
Previous Dentist's Name
Address
How often do you have dental examinations?
How often do you brush your teeth?
How often do you floss?
What other dental aids do you use? (Interplak, toothpick, etc.)
Do you have any dental problems now?

YesNo
If yes, please describe
Are any of your teeth sensitive to:
Hot or Cold?

YesNo
Sweets?

YesNo
Biting or Chewing?

YesNo
Have you noticed any mouth odors or bad tastes?

YesNo
Do you frequently get cold sores, blisters or any other oral lesions?

YesNo
Do your gums bleed or hurt?

YesNo
Have your parents experienced gum disease or tooth loss?

YesNo
Have you noticed any loose teeth or change in your bite?

YesNo
Does food tend to get caught in between your teeth?

YesNo
Have you ever had instruction of the correct way to brush your teeth?

YesNo
Do you:
Clench or grind your teeth while awake or asleep?

YesNo
Bite your lips or cheeks regularly?

YesNo
Hold foreign objects with your teeth? (pencils, pipe, pins, nails, fingernails)

YesNo
Mouth breathe while awake or asleep?

YesNo
Have tired jaws, especially in the morning?

YesNo
Smoke/chew tobacco?

YesNo
Have you ever had:
Orthodontic treatment?

YesNo
Oral Surgery?

YesNo
Periodontal treatment?

YesNo
Your teeth ground or the bite adjusted?

YesNo
A bite plate or mouth guard?

YesNo
A serious injury to the mouth or head?

YesNo
If so, please describe including cause:
Have you experienced:
Clicking or popping of the jaw?

YesNo
Pain? (joint, ear, side of face)

YesNo
Difficulty in opening or closing the mouth?

YesNo
Difficulty in chewing on either side of the mouth?

YesNo
Headaches, neckaches or shoulder aches?

YesNo
Are you satisfied with your teeth's appearance?

YesNo
Would you like to keep all your teeth all of your life?

YesNo
Do you feel nervous about having dental treatment?

YesNo
If so, what is your biggest concern?
Have you ever had an upsetting dental experience?

YesNo
If yes, please describe:
Is there anything else about having dental treatment that you would like us to know?

YesNo
If yes, please describe:
Health History
Are you experiencing any discomfort at this time?

YesNo
If yes, please describe
Are you now under the care of a physician?

YesNo
Physician's Name:
Physician's Address:
Date of last physical examination:
Are you in good health?

YesNo
Have you been hospitalized, had a serious operation or illness within the past 5 years?

YesNo
If so, what was the problem?
Do you have or have you had any of the following diseases or problems?

Heart Surgery, Disease, or AttackAngina/Chest PainHigh or Low Blood PressureHeart MurmurRheumatic FeverCongenital Heart DiseaseScarlet FeverArtificial Heart ValveHeart PacemakerMitral Valve ProlapseA.I.D.S or HIV Related DisordersHepatitis A (infectious) B (serum) otherLiver DiseaserYellow JaundiceEmphysemaChronic CoughTuberculosisAsthmaHay FeverLatex SensitivityAllergies or HivesArtificial Joint (Hip, Knee, Etc.)AnemiaStrokeKidney TroubleUlcers/ColitisBruise EasilyHemophiliaSickle Cell DiseaseBleeding ProblemsPsychiatric CareNeurological DisordersDiabetesThyroid DiseaseChemotherapyArthritis/RheumatismGlaucomaPain in Jaw Joints (TMJ)Fainting or Dizzy SpellsEpilepsy or SeizuresCold Sores (Fever Blisters)STD or VD (Syphilis or Gonorrhea)Blood TransfusionNervousnessContact LensesDiet (Special, Restricted)Other
Are you taking any medication(s), drugs, or pills; including non-prescription medicine(s)?

YesNo
If yes, please list name and dosage:
Are you aware of having an allergic (or adverse reaction) to any medication or substance?

YesNo
Please check any or all which apply:

Local Anesthetics (Novocaine)Penicillin or Other AntibioticsSulfa DrugsBarbiturates/SedativesIodineAspirinCodeine/Other NarcoticsOther
Do you use tobacco products?

YesNo
If so, what types and amount:
Have you used tobacco products in the past?

YesNo
Do you use alcohol?

YesNo
Do you use cocaine, or other drugs?

YesNo
Are you a recovering drug addict or alcoholic?

YesNo
Do you have any disease, condition, or problem not listed on this form that you think I should know about?

YesNo
If yes, please explain:
For Women Only
Are you pregnant, or you think you may be pregnant?

YesNoN/A
Are you nursing?

YesNoN/A
Are you taking birth control pills?

YesNoN/A
I UNDERSTAND ALL INFORMATION IS NECESSARY TO PROVIDE ME 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 THE RESPECTIVE HEALTH CARE PROVIDER OR AGENCY, WHO MAY RELEASE INFORMATION TO YOU. I WILL NOTIFY THE DOCTOR OF ANY CHANGE IN MY HEALTH OR MEDICATION.
PATIENT/GUARDIAN SIGNATURE

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Date
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Health History

DAVIS & ROBERTSON D.M.D P.S.C.

DENTAL HISTORY

Do you:

Have you ever had:

Have you experienced:

Health History

For Women Only