Registration and Medical History Forms
DENTAL HEALTH REASONS FOR FILLING OUT DENTAL AND MEDICAL HISTORY FORMS
We are frequently asked by patients as to why they need to fill out medical and dental history forms. Patients often do not realize that their dental health affects their physical health and that their physical health affects their dental health.
When we get your complete medical and dental history, we are able to help you understand the connection between your oral health and general health.
Our dental exams can help diagnose periodontal disease (gum disease), cavities, oral cancer and other health conditions that maybe connected to diabetes, heart disease and other medical concerns. Because of how these risk factors are related to each other you will be asked additional questions regarding your health. By answering these questions, we are able to make recommendations that are SPECIFIC TO YOU.
Medications that patients take can also have side effects that affect oral health. Many patients are taking some kind of medication, and many of these medications could have a dental related side effect. Please take the time to answer these questions carefully so that we can give you the best care possible.
LAST FIRST MI MR MRS MS DR
SECONDARY DENTAL INSURANCE
Best time and place to reach you:
Who may we thank for referring you?
Other family members seen by us?
Person responsible for account:
Group # (plan, local policy#):
Group# (plan, local policy#):
GENERAL MEDICAL INFORMATION
Has there been a change in your health in the past year?
Date of last physical examination:
Currently under the care of a physician?
Do you excercise regularly?
Do you need to take antibiotics prior to receiving dental or surgical care?
MAJOR HOSPITALIZATIONS, SURGERIES, OR BLOOD TRANSFUSIONS
ALLERGIC OR UNUSUAL REACTION TO ANY OF THE FOLLOWING
PRESCRIPTIONS/NON-PRESCRIIPTION MEDICATIONS, VITAMINS, AND SUPPLEMENTS
Please list all Name For What Condition? Dose/frequency of use
If yes please answer the following questions
Are you interested in quitting tobacco?
Frequency of Dental exams:
What are some typical foods you eat between meals?
What type of beverages between meals?
Do you often use hard candy, cough drops or mints?
Do you use fluoridated toothpaste?
Primary sources of drinking water?.
One or more fillings in the last three yrs?
Family history of extensive decay?
Treatment for periodontal (gum) disease?
Family history of periodontal disease?
Have you had orthodontics (Braces)?
Have you had oral surgery?
Have you had dental implants placed?
Treatment for TMJ disorders?
Do you wear dentures or partial dentures?
DO YOU HAVE ANY PROBLEMS WITH?
Dry mouth/excessive thirst?
Sensitive teeth or hot,cold
Cold sores, blisters,oral lesions?
Are you aware of any swelling or
Food catches between teeth?
Clenching or grinding habits?
Does dental work make you
Your smile or esthetics of your