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

Month Day Year
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?

Yes No
If yes, please describe
Are any of your teeth sensitive to:
Hot or Cold?

Yes No
Sweets?

Yes No
Biting or Chewing?

Yes No
Have you noticed any mouth odors or bad tastes?

Yes No
Do you frequently get cold sores, blisters or any other oral lesions?

Yes No
Do your gums bleed or hurt?

Yes No
Have your parents experienced gum disease or tooth loss?

Yes No
Have you noticed any loose teeth or change in your bite?

Yes No
Does food tend to get caught in between your teeth?

Yes No
Have you ever had instruction of the correct way to brush your teeth?

Yes No
Do you:
Clench or grind your teeth while awake or asleep?

Yes No
Bite your lips or cheeks regularly?

Yes No
Hold foreign objects with your teeth? (pencils, pipe, pins, nails, fingernails)

Yes No
Mouth breathe while awake or asleep?

Yes No
Have tired jaws, especially in the morning?

Yes No
Smoke/chew tobacco?

Yes No
Have you ever had:
Orthodontic treatment?

Yes No
Oral Surgery?

Yes No
Periodontal treatment?

Yes No
Your teeth ground or the bite adjusted?

Yes No
A bite plate or mouth guard?

Yes No
A serious injury to the mouth or head?

Yes No
If so, please describe including cause:
Have you experienced:
Clicking or popping of the jaw?

Yes No
Pain? (joint, ear, side of face)

Yes No
Difficulty in opening or closing the mouth?

Yes No
Difficulty in chewing on either side of the mouth?

Yes No
Headaches, neckaches or shoulder aches?

Yes No
Are you satisfied with your teeth's appearance?

Yes No
Would you like to keep all your teeth all of your life?

Yes No
Do you feel nervous about having dental treatment?

Yes No
If so, what is your biggest concern?
Have you ever had an upsetting dental experience?

Yes No
If yes, please describe:
Is there anything else about having dental treatment that you would like us to know?

Yes No
If yes, please describe:
Health History
Are you experiencing any discomfort at this time?

Yes No
If yes, please describe
Are you now under the care of a physician?

Yes No
Physician's Name:
Physician's Address:
Date of last physical examination:
Are you in good health?

Yes No
Have you been hospitalized, had a serious operation or illness within the past 5 years?

Yes No
If so, what was the problem?
Do you have or have you had any of the following diseases or problems?

Heart Surgery, Disease, or Attack Angina/Chest Pain High or Low Blood Pressure Heart Murmur Rheumatic Fever Congenital Heart Disease Scarlet Fever Artificial Heart Valve Heart Pacemaker Mitral Valve Prolapse A.I.D.S or HIV Related Disorders Hepatitis A (infectious) B (serum) other Liver Diseaser Yellow Jaundice Emphysema Chronic Cough Tuberculosis Asthma Hay Fever Latex Sensitivity Allergies or Hives Artificial Joint (Hip, Knee, Etc.) Anemia Stroke Kidney Trouble Ulcers/Colitis Bruise Easily Hemophilia Sickle Cell Disease Bleeding Problems Psychiatric Care Neurological Disorders Diabetes Thyroid Disease Chemotherapy Arthritis/Rheumatism Glaucoma Pain in Jaw Joints (TMJ) Fainting or Dizzy Spells Epilepsy or Seizures Cold Sores (Fever Blisters) STD or VD (Syphilis or Gonorrhea) Blood Transfusion Nervousness Contact Lenses Diet (Special, Restricted) Other
Are you taking any medication(s), drugs, or pills; including non-prescription medicine(s)?

Yes No
If yes, please list name and dosage:
Are you aware of having an allergic (or adverse reaction) to any medication or substance?

Yes No
Please check any or all which apply:

Local Anesthetics (Novocaine) Penicillin or Other Antibiotics Sulfa Drugs Barbiturates/Sedatives Iodine Aspirin Codeine/Other Narcotics Other
Do you use tobacco products?

Yes No
If so, what types and amount:
Have you used tobacco products in the past?

Yes No
Do you use alcohol?

Yes No
Do you use cocaine, or other drugs?

Yes No
Are you a recovering drug addict or alcoholic?

Yes No
Do you have any disease, condition, or problem not listed on this form that you think I should know about?

Yes No
If yes, please explain:
For Women Only
Are you pregnant, or you think you may be pregnant?

Yes No N/A
Are you nursing?

Yes No N/A
Are you taking birth control pills?

Yes No N/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