Dental History

Patient First Name:
Patient Last Name:
How would you rate your smile? 1 (I don't know where to start) to 10 (I love it):
One area that you would like to change with your smile?

Has the patient had an orthodontic consult or treatment? If so, when?
Does the patient need to premedicate with antibiotics prior to dental visit?
Any injuries/accidents to face or teeth? Describe

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Difficulty chewing?
Difficulty swallowing?
Difficulty speaking?
Thumb or finger sucking?
Mouth breathing?
Snoring at night?
Grinding teeth at night?
Popping/clicking in the jaw joints?
Any gum tissue concerns or previous treatments?
Any additional dental information?

Medical History

Are you on any medications? If yes, please list:
Are you taking/have taken osteoporosis medication? If yes, please list:
Are you allergic to any medications? If yes, please list:
Are you allergic to Latex?

Please select 'Yes' if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Abnormal bleeding?
Have tonsils or adenoids been removed?
Arthritis?
Artificial limbs or joint replacements?
Asthma?
Blood transfusion?
Cancer?
Chronic ear infections?
Diabetes?
Dizziness?
Frequent headaches?
Frequent neck or backaches?
Ringing in the ears?
Heart murmur?
Hepatitis?
HIV / AIDS?
Rheumatic / Scarlet fever?
Tuberculosis?
Smoke or use nicotine products?
Other condition or problem that you think we should know about? Please describe: