Adult Form
Patient's Name:
Patient's Name:
Address:
Address:
Home Phone:
Home Phone:
Cell Phone:
Cell Phone:
Other Family Treated?
Work Phone:
Work Phone:
Do you take antibiotics prior to dental appointments?
Chipped or otherwise injured permanent teeth?
Teeth sensitive to hot or cold?
Teeth throb or ache?
Jaw fractures, facial trauma, cysts, mouth infections?
Bleeding gums, bad taste, mouth odor?
Periodontal or "gum problems?"
Frequent canker sores, cold sores?
Abnormal swallowing habit or "tongue thrusting?"
Mouth breathing habit, difficulty in breathing?
History of finger or thumb sucking?
Tooth grinding, jaw clenching, clicking or locking?
Do you experience any pain or soreness in the muscles of your face, or around your ears?
Have you ever been treated for "TMJ" problems (jaw joint or facial muscle pain)?
Difficulty chewing or opening jaw?
History of supernumerary (extra) or congenitally missing teeth?
Have any permanent teeth been removed?
Aware of loose, broken or missing fillings?
Any teeth irritating cheek, lip, tongue or palate?
Have you ever had Orthodontic treatment (braces, expander, or worn a retainer?)
Have you recently been under another dentist's or specialist's care?
Have you ever had Periodontal (gum) treatment?
Concerned about spaced, crooked, protruding teeth?
Aware or concerned about under or over-developed jaws?
Any relative with similar tooth or jaw relationships?
Any wisdom tooth problems?
Have you had any serious trouble associated with any previous dental treatment?
Has anyone in the family received orthodontic treatment?
Heart murmur
History of rheumatic fever?
Rhuematoid or arthritic conditions?
Endocrine or thyroid problems?
Kidney problems?
Diabetes?
Cancer or been treated for a tumor?
Stomach ulcer or hyperacidity?
Polio, mononucleosis, tuberculosis, pneumonia?
Problems of the immune system?
Hepatitis, jaundice or liver problem?
AIDS or HIV Positive?
Fainting spells, seizures, epilepsy or neurologic disease?
Mental health or behavrial problems?
Vision, hearing, tasting or speech difficulties?
Loss of weight recently, poor appetite?
Excessive bleeding, black and blue tendency, anemic or bleeding disorder?
High or low blood pressure?
Cardiovascular problems (heart trouble, heart attack angina, coronary insufficiency, arteriosclerosis, stroke, inborn heart defects or rheumatic heart)?
Skin disorder?
Frequent headaches, colds or sore throats?
Any history of speech problems?
Eye, ear, nose or throat condition?
Hayfever, asthma, sinus trouble, hives?
Tonsil or adenoid conditions?
Are you currently taking or have you ever taken bisphosphonates or been treated for osteoporosis, osteopenia, bone disorder, or bone cancer?
Allergies or drug reactions?
Are you taking medications, nutrient supplements or non-prescription medicine?
Are you currently being treated by a health care professional?
Female Patients Only
Are you pregnant?
Are you taking birth control pills?
Are you anticipating getting pregnant?