Dental Medical Questionnaire (2022rev1)

"*" 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*

MM slash DD slash YYYY

Date of most recent x-rays

MM slash DD slash YYYY

Date of most recent treatment (other than cleaning)*

MM slash DD slash YYYY

I routinely see my dentist every:*

3 months

4 months

6 months

12 months

Not routinely

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

Yes

5) Have you had any teeth removed?*

Yes

BITE AND JAW JOINT

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

Yes

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

Yes

8) Are your teeth crowding or developing spaces?*

Yes

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

SMILE CHARACTERISTICS

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

Yes

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

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*

None

aspirin ibuprofen acetaminophen

codeine

penicillin

erythromycin

tetracycline

sulfa

local anesthetic

fluoride

metals (nickel gold silver)

latex

other (list box)

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*

Yes

6) Pacemaker or implantable defibrillator*

Yes

7) Artificial prosthesis (orthopedic joint replacement)*

Yes

8) High or low blood pressure*

Yes

9) A stroke, or, are you taking blood thinners for any reason*

Yes

10) Anemia or other blood disorder*

Yes

11) Emphysema, shortness of breath, sarcoidosis*

Yes

12) Tuberculosis, measles, chicken pox*

Yes

13) Asthma*

Yes

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

Yes

15) Kidney, liver disease, or jaundice*

Yes

16) Thyroid, parathyroid disease, or calcium deficiency*

Yes

17) Hormone deficiency*

Yes

18) High cholesterol or taking statin drugs*

Yes

19) Diabetes*

Yes

20) Stomach or duodenal ulcer*

Yes

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

Yes

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

Yes

If you answered YES to #19, enter your HbA1c

23) Arthritis, rheumatoid arthritis, lupus*

Yes

24) Contact lenses*

Yes

25) Head or neck injuries*

Yes

26) Epilepsy, convulsions (seizures)*

Yes

27) Neurologic disorders (ADD/ADHD)*

Yes

28) Viral infections and cold sores*

Yes

29) Any lumps or swelling in the mouth*

Yes

30) Hives, skin rash, hay fever*

Yes

31) STD, HIV/AIDS, Hepatitis*

Yes

32) Tumor, abnormal growth, Radiation therapy, Chemotherapy, immunosuppressive,*

Yes

33) Emotional problems, Psychiatric treatment, Antidepressant medication*

Yes

This field is hidden when viewing the form

37) Hepatitis (select)

-

DO YOU HAVE or HAVE YOU EVER HAD:

34) Presently being treated for any other illness*

Yes

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

Yes

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

Yes

37) Experiencing frequent headaches*

Yes

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

Yes

39) FEMALE - taking birth control pills

Yes

40) FEMALE - pregnant

Yes

41) 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*

Month

Day

Year

Comments

This field is for validation purposes and should be left unchanged.