DENTAL HISTORY - d3ciwvs59ifrt8.cloudfront.net · Forest Drive Dental Care 5101 Forest Drive...

803.782.8786

DENTAL HISTORY

What is the reason for your visit today?

Checkup/cleaning

Implant Evaluation

If other, please describe

Date of Last Cleaning

Q 4 - 6 months ago

Q more than 2 years ago

I have recent (within 1-3 years) x-rays at another dental office.

Tooth Ache

Denture Evaluation

Q 6-12 months ago

Previous Dentist's Name, Address, Phone number

How often do you brush your teeth?

Q Once a day Q Twice a day

Orthodontic Evaluation

Q 12 - 24 months ago

Q More than twice a day

Q Occasionally (1-3 times per week)

How often do you floss or use a water flosser (WaterPik)?

Q Never

Q Frequently (more than 4 times per week)

Do you use a toothpaste or mouthwash containing flouride?

[email protected]

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www.columbiadentistry.com 5101 Forest Drive, Ste. A Columbia, SC 29206

Amalgam Removal

Yes No

Lip Enhancement/Dermal Filler Other

Forest Drive Dental Care 5101 Forest DriveColumbia, SC 29206

Do you have any dental problems now?

Qves QNo

If yes, please describe:

Are any of your teeth sensitive to:

Hot or Cold Sweets Biting or Chewing

Do you:

Notice any mouth odors or bad tastes?

Frequently get cold sores, blisters, or any other oral lesions?

Experience bleeding or any discomfort in your gums?

Clench or grind your teeth while awake or asleep?

Bite your lips or cheeks regularly?

Hold foreign objects with your teeth?

Mouth breathe while awake or asleep?

Have tired jaws, especially in the morning?

Snore or have any other sleeping disorders?

Smoke/chew tobacco or use tobacco products?

Have you or your parents experienced gum disease or tooth loss?

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

www.columbiadentistry.com

[email protected]

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803.782.8786

Qves

If yes, where does food get caught between your teeth?

Have you ever had:

Orthodontic treatment (braces)?

Periodontal treatment (gum disease)?

A bite plate or mouth guard?

Oral Surgery (extractions)?

Your teeth ground or the bite adjusted?

A serious injury to the mouth or head?

If you have had an injury, please describe, including cause:

Have you experienced:

Clicking or popping of the jaw? Pain? Uoint, ear, side of face)


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Difficulty in opening or closing your mouth?

Headaches, neckaches or shoulder aches?

Difficulty in chewing on either side of the mouth?

Please describe:

Are you satisfied with your teeth's appearance?

Qves QNo

If no, please describe

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Forest Drive Dental Care 5101 Forest DriveColumbia, SC 29206803.782.8786

Does food get caught between your teeth?

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

Oves

Do you feel nervous about having dental treatment?

Qves

If yes, what is your biggest concern?

Have you had an upsetting dental experience?

Qves

If yes, please describe

Have you ever been told to take a pre-medication (antibiotic) prior to dental treatment?

Oves

If yes, for what for what reason?

Is there anything else about having dental treatment that you would like us to know?

Oves


MEDICAL HISTORY

Physician's Name, Address and Phone


[email protected]

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Forest Drive Dental Care 5101 Forest DriveColumbia, SC 29206 803.782.8786

Have you had any medical care or surgeries in the past two years?

Qves


Have you taken any prescription or non-prescription drugs in the past 2 years?

Qves QNo


[email protected]

Are you currently taking any medications, drugs, pills or herbal remedies, including regular dosages of asprin?

Qves QNo

If yes, please list names and dosage

Have you ever taken prescription medications for weight loss (diet pills)? Qves QNo

If yes, did you take any of the following?

Fen-Phen Pondimen Redux Other

Have you noticed any sensitivity to metals in jewerly or dental materials?

Qves QNo

Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or other similar drugs?

Qves QNo

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[email protected]

Are you aware of having an allergic (or adverse) reaction to any substance or medication?

Qves

If yes, please specify

Have you been a patient in the hospital during the past five years?

Qves QNo


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

Heart (Surgery, Disease, Attack)

Heart Murmur

Artificial HeartValve/Pacemaker

Cortisone Medicine

Diet (Special/Restricted)

Ulcers

Glaucoma

Chronic Cough

Hay Fever/Allergy/Hives

Radiation Therapy

Hepatitis A

Blood Transfusion

Bruise Easily

Epilepsy or Seizures Psychiatric/

Psychological Care

Chest Pain

High/Low Blood Pressure

Rheumatic Fever

Swollen Ankles

Artificial Joints (Hip, Knee, etc)

Diabetes

Contact Lenses

Tuberculosis

Latex Sensitivity

Chemotherapy

Hepatitis B

A.I.D.S/H.I.V Positive

Hemophilia

Liver Disease/Yellow Jaundice

Fainting or Dizzy Spells

Congenital Heart Disease

Mitral Valve Prolapse

Arthritis/Rheumatism

Stoke

Kidney Trouble

Thyroid Problems

Emphysema

Asthma

Sinus Trouble

Tumors

Hepatitis C

Cold Sores/Fever Blisters

Sickle Cell Disease

Neurological Disorders

Nervous/Anxious

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Have you lost or gained more than 10 pounds in the past year?

Qves

Do you have or have you had any disease, condition, or problem not listed?

Qves

If yes, please list.


[email protected]

Is there anything else you would like us to know about you before your dental visit?

Women: Are you pregnant or think you could be pregnant?

Qves QNo

Are you nursing?

Qves QNo

Do you use birth control prescriptions?

Qves QNo

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 my 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.

History Review (for office use only)

Response Date:

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Forest Drive Dental Care 5101 Forest DriveColumbia, SC 29206803.782.8786

Patient Name Signature Date

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