San Diego Dentist and Cosmetic Dentist

DENTAL HISTORY

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This information is necessary for our files and will be kept CONFIDENTIAL.

Date

Patient Name
	Last	First	Initial

What is the reason for your visit today?

Previous dentist name

Address

Phone


How often do you have a dental examination?

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 problem, pain or sensitivity now?	YES	NO
If yes, please describe:
Do you feel nervous about having dental treatment?	YES	NO
If yes, what is your biggest concern?
Have you ever had orthodontic treatment?	YES	NO
Have you ever had oral surgery? .	YES	NO
Have you ever had periodontal (gum) treatment?	YES	NO
Have you ever had clicking or popping of jaw?	YES	NO
Have you ever had joint pain?	YES	NO
Have you ever had difficulty in opening or closing your mouth?	YES	NO
Have you ever had mouth odor or bad taste? ..	YES	NO
Have you ever had dry mouth?	YES	NO
Have you ever had food getting caught between your ..teeth?	YES	NO
Have you ever had an upsetting dental experience?	YES	NO
Do you clench or grind your teeth while awake or asleep?	YES	NO
Do you breathe through your mouth?	YES	NO
Do you have tired jaw, especially in the morning?	YES	NO
Do you smoke cigarettes or cigars?	YES	NO
If yes, how many a day?
Do you Chew tobacco?	YES	NO
Are you satisfied with your teeth’s appearance?	YES	NO
Would you like to have whiter teeth?	YES	NO
Is there anything else about dental treatment that you would like us to know?	YES	NO
If yes, please describe:

MEDICAL HISTORY

Are you in good general health?	YES	NO
Are you being treated for any illness now?	YES	NO
If yes, please describe:

Your physician’s name

Address

Phone

Are you taking medication, drugs or pills now?	YES	NO
If yes, please describe:

Are you taking Phen-fen now?	YES	NO
Are you aware of having allergic reactions to any medication or substances?	YES	NO
If yes, please describe:
Have you been hospitalized during the past five years?	YES	NO
If yes, please describe:

Indicate which of the following you have had, or have at present

Heart disease, surgery, attack

YES

NO

Swollen ankles

YES

NO

Radiation therapy

YES

NO

Heart defect

YES

NO

Fainting, dizzy spells

YES

NO

Cancer

YES

NO

Artificial heart valve

YES

NO

Stroke

YES

NO

Chemotherapy

YES

NO

Heart murmur

YES

NO

Diet

YES

NO

Tumors

YES

NO

Congenital heart disease

YES

NO

Kidney trouble

YES

NO

Venereal disease

YES

NO

Mitral valve prolapse .

YES

NO

Ulcers

YES

NO

A.I.D.S

YES

NO

Rheumatic fever.

YES

NO

Diabetes

YES

NO

H.I.V. positive

YES

NO

High blood pressure ..

YES

NO

Thyroid problems

YES

NO

Cold sores, fever blisters

YES

NO

Chest pain ..

YES

NO

Glaucoma

YES

NO

Blood transfusion

YES

NO

Heart pacemaker

YES

NO

Contact lenses

YES

NO

Hemophilia

YES

NO

Artificial joints

YES

NO

Hay fever

YES

NO

Sickle cell disease

YES

NO

TB, emphysema.

YES

NO

Latex sensitivity

YES

NO

Bruise easily

YES

NO

Chronic cough..

YES

NO

Allergies or hives

YES

NO

Liver disease

YES

NO

Asthma.

YES

NO

Sinus trouble

YES

NO

Yellow jaundice

YES

NO

Arthritis, rheumatism

YES

NO

Psychiatric, psychological care

YES

NO

Epilepsy, seizures

YES

NO

Cortisone medication

YES

NO

Hepatitis

YES

NO

Recreational drugs	YES	NO	If YES , how much?
Alcohol	YES	NO	If YES , how much?

Have you lost or gained more than 10 pounds in the past year?	YES	NO
Do you have or have you had any disease, condition or problem not listed?	YES	NO
If yes, please describe:

Women

Are you pregnant?

YES

NO

months.

Are you nursing?

YES

NO

Are you taking birth control?

YES

NO

I understand the above 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 permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.

Signature of Patient (Parent if Minor)	Date	Dr.

Recall Review
Signature of Patient (Parent if Minor)	Date	Dr.
Signature of Patient (Parent if Minor)	Date	Dr.
Signature of Patient (Parent if Minor)	Date	Dr.