To be eligible to fill out a dental medical history form, you must be a patient of the dental office.
Emergency Contact Number
Do your gums bleed when you brush?
Have you ever had orthodontic (braces) treatment?
Are your teeth sensitive to cold, hot, sweets or pressure?
Do you have earaches or neck pains?
Have you had any periodontal (gum) treatments?
Do you wear removable dental appliances?
Have you had a serious/difficult problem associated with any previous dental treatment?
if yes, explain
How would you describe your current dental problem?
Date of your last dental exam
Date of last dental x-rays
Are you in good health?
Has there been any change in your general health within the past year?
Are you now under the care of a physician?
Do you use drugs or other substances forrecreational purposes?
Has a physician or previous dentist recommendedthat you take antibiotics prior to your dental treatment?