Dental & Medical Questionnaire Form

Dental Medical Questionnaire (2022)

"*" indicates required fields

First Name*

Last Name*

Nickname

Age*

Email*

Enter Email Confirm Email

Referred by

How would you rate the condition of your mouth?*

Excellent

Good

Fair

Poor

Previous or Current Dentist*

How long were you a patient?

Date of most recent exam*

Date of most recent x-rays

Date of most recent treatment (other than cleaning)*

I routinely see my dentist every:*

What is your immediate concern?

PLEASE ANSWER YES OR NO TO THE FOLLOWING:

PERSONAL HISTORY

1) Are you fearful of dental treatment? Enter 1 to 10 **

2) Have you had an unfavorable dental experience?*

Yes

3) Have you ever had complications from past dental treatment?*

Yes

4) Have you ever had complications from past dental treatment?*

Yes

5) Did you ever have braces, orthodontic treatment or had your bite adjusted?*

Yes

6) Have you had any teeth removed?*

Yes

BITE AND JAW JOINT

7) Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?*

Yes

8) Have your teeth changed in the last 5 years, become shorter, thinner or worn?*

Yes

9) Are your teeth crowding or developing spaces?*

Yes

10) Do you have more than one bite and squeeze to make your teeth fit together?*

Yes

11) Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?*

Yes

12) Do you clench your teeth in the daytime or make them sore?*

Yes

13) Do you have any problems with sleep or wake up with an awareness of your teeth?*

Yes

14) Do you wear, or have you ever worn a bite appliance?*

Yes

SMILE CHARACTERISTICS

15) Is there anything about the appearance of your teeth that you would like to change?*

Yes

16) Have you ever whitened (bleached) your teeth?*

Yes

17) Have you felt uncomfortable or self-conscious about the appearance of your teeth?*

Yes

18) Have you been disappointed with the appearance of previous dental work?*

Yes

PART 2 - MEDICAL HISTORY

Please enter your medical history

Name of Physician/and their specialty*

Most recent physical examination*

Purpose

What is your estimate of your general health?*

Excellent

Good

Fair

Poor

DO YOU HAVE or HAVE YOU EVER HAD:

1) Hospitalization for illness or injury*

Yes

2) An allergic reaction to*

Other (list items)

3) Heart problems, or cardiac stent within the last six months*

Yes

4) History of infective endocarditis*

Yes

5) Artificial heart valve, repaired heart defect (PFO)*

Yes

6) Pacemaker or implantable defibrillator*

Yes

7) Artificial prosthesis (heart valve or joints)*

Yes

8) Rheumatic or scarlet fever*

Yes

9) High or low blood pressure*

Yes

10) A stroke (taking blood thinners)*

Yes

11) Anemia or other blood disorder*

Yes

12) Prolonged bleeding due to a slight cut (INR > 3.5)*

Yes

13) Emphysema, shortness of breath, sarcoidosis*

Yes

14) Tuberculosis, measles, chicken pox*

Yes

15) Asthma*

Yes

16) Breathing or sleep problems (i.e. sleep apnea, snoring, sinus)*

Yes

17) Kidney disease*

Yes

18) Liver disease*

Yes

19) Jaundice*

Yes

20) Thyroid, parathyroid disease, or calcium deficiency*

Yes

21) Hormone deficiency*

Yes

22) High cholesterol or taking statin drugs*

Yes

If you answered YES to #23, enter your HbA1c

23) Diabetes*

Yes

24) Stomach or duodenal ulcer*

Yes

25) Digestive disorders (i.e. celiac disease, gastric reflux)*

Yes

26) Osteoporosis/osteopenia (i.e. taking bisphosphonates)*

Yes

27) Arthritis, rheumatoid arthritis, lupus*

Yes

28) Glaucoma*

Yes

29) Contact lenses*

Yes

30) Head or neck injuries*

Yes

31) Epilepsy, convulsions (seizures)*

Yes

32) Neurologic disorders (ADD/ADHD, prion disease)*

Yes

33) Viral infections and cold sores*

Yes

34) Any lumps or swelling in the mouth*

Yes

35) Hives, skin rash, hay fever*

Yes

36) STI / STD*

Yes

37) Hepatitis (select)*

38) HIV / AIDS*

Yes

39) Tumor, abnormal growth*

Yes

40) Radiation therapy*

Yes

41) Chemotherapy, immunosuppressive*

Yes

42) Emotional problems*

Yes

43) Psychiatric treatment*

Yes

44) Antidepressant medication*

Yes

45) Alcohol / street drug use*

Yes

DO YOU HAVE or HAVE YOU EVER HAD:

46) Presently being treated for any other illness*

Yes

47) Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea)*

Yes

48) Taking medication for weight management (i.e. fen-phen)*

Yes

49) Taking dietary supplements*

Yes

50) Often exhausted or fatigued*

Yes

51) Experiencing frequent headaches*

Yes

52) A smoker, smoked previously or use smokeless tobacco*

Yes

53) Considered a touchy person*

Yes

54) Often unhappy or depressed*

Yes

55) FEMALE - taking birth control pills

Yes

56) FEMALE - pregnant

Yes

57) MALE - prostate disorders

Yes

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)

List all medications, supplements, and or vitamins taken within the last two years

Please bring a list of your medications if greater then 4 medications.

Drug

Purpose

Drug

Purpose

Drug

Purpose

Drug

Purpose

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Electronic Signature of Patient (or Guardian)*

By typing your name in the space below you are providing an "electronic signature" and it indicates your approval of the information contained in this electronic form.

Type Full Name Below*

Electronic Signature

Date Signed*