Adult Patient Medical Dental History Form

Patient Health Information

List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements, that you take.

Medication & Length Taken

Do you take antibiotic pre-medication before dental procedures?

Yes
No

How many times a week do you consume alcohol?

Do you chew or smoke tobacco?

Have you noticed any changes in your face or jaws?

How often do you brush?

How often do you floss?

Women: Are you pregnant?

Yes
No

Women: Are you trying to become pregnant?

Yes
No

DENTAL HISTORY

Now or in the past, have you had:

Have you ever taken intravenous medication for bone disorders or cancer such as bisphosphonates as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate)?

Yes
No

Have you ever taken oral medication for bone disorders such as bisphosphonates Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate)?

Yes
No

Birth defects or hereditary problems?

Yes
No

Bone fractures, or major injuries?

Yes
No

Any injuries to face, head, neck?

Yes
No

Arthritis or joint problems?

Yes
No

Endocrine or thyroid problems?

Yes
No

Diabetes or low sugar?

Yes
No

Kidney problems?

Yes
No

Cancer, tumor, radiation treatment or chemotherapy?

Yes
No

Stomach ulcer, hyperacidity, acid reflux?

Yes
No

Immune system problems?

Yes
No

History of osteoporosis?

Yes
No

Gonorrhea, syphilis, herpes, sexually transmitted diseases?

Yes
No

AIDS or HIV positive?

Yes
No

Hepatitis, jaundice or other liver problem?

Yes
No

Polio, mononucleosis, tuberculosis, pneumonia?

Yes
No

Seizures, fainting spells, neurologic problem?

Yes
No

Mental health disturbance or depression?

Yes
No

Vision, hearing, or speech problems?

Yes
No

History of eating disorder (anorexia, bulimia)?

Yes
No

High or low blood pressure?

Yes
No

Excessive bleeding or bruising, anemia?

Yes
No

Chest pain, shortness of breath, tire easily, swollen ankles?

Yes
No

Heart defects, heart murmur, rheumatic heart disease?

Yes
No

Angina, arteriosclerosis, stroke or heart attack?

Yes
No

Skin disorder (other than common acne)?

Yes
No

Do you eat a well-balanced diet?

Yes
No

Frequent headaches or migraines?

Yes
No

Frequent ear infections, colds, throat infections?

Yes
No

Asthma, sinus problems, hayfever?

Yes
No

Tonsil or adenoid condition?

Yes
No

Do you frequently breathe through your mouth?

Yes
No

Permanent or extra (supernumerary) teeth removed?

Yes
No

Supernumerary (extra) or congenitally missing teeth?

Yes
No

Chipped or injured primary or permanent teeth?

Yes
No

Any sensitive or sore teeth?

Yes
No

Bleeding gums, bad taste or mouth odor?

Yes
No

Jaw fractures, cysts, infections?

Yes
No

Any teeth treated with root canals or pulpotomies?

Yes
No

“Gum boils,” frequent canker sores or cold sores?

Yes
No

History of speech problems or speech therapy?

Yes
No

Difficulty breathing through nose?

Yes
No

Food impaction between the teeth?

Yes
No

Mouth breathing habit or snoring at night?

Yes
No

History of speech problems?

Yes
No

Frequent oral habits (sucking finger, chewing pen, etc.)?

Yes
No

Teeth causing irritation to lip, cheek or gums?

Yes
No

Abnormal swallowing (tongue thrust)?

Yes
No

Tooth grinding or clenching?

Yes
No

Clicking, locking in jaw joints?

Yes
No

Soreness in jaw muscles or face muscles?

Yes
No

Ringing in ears, difficulty in chewing or opening jaw?

Yes
No

Have you ever been treated for “TMJ” or “TMD” problems?

Yes
No

Any broken or missing fillings?

Yes
No

Any serious trouble associate with previous dental treatment?

Yes
No

Have you ever been diagnosed with gum disease or pyorrhea?

Yes
No

Have you ever had an orthodontic consultation or treatment before now?

Yes
No

Allergies

Have you had allergies or reactions to any of the following:

Latex (gloves, balloons)

Yes
No

Metals (jewelry, clothing snaps)

Yes
No

Acrylics

Yes
No

Local anesthetics (novocaine, lidocaine, xylocaine)

Yes
No

Aspirin

Yes
No

Ibuprofen (Motrin, Advil)

Yes
No

Penicillin

Yes
No

Other antibiotics

Yes
No

Plant pollens

Yes
No

Step 1 of 3

Dr. Pam Orthodontics

Patient

Closest Relative

Dentist

General Information

Financial Responsibility

Dental Insurance

Patient Health Information

DENTAL HISTORY

Allergies

Release and Waiver

Patient HIPPA Awareness