GENERAL HEALTH INFORMATION

Date:

PATIENT NAME:

BIRTH DATE:

AGE:

1.Reason for Visit / Main Concern? Check-Up Cleaning Toothache

Other

2.Are there other conditions of which we should be aware? YES NO

If yes, please specify:

3.When did you last visit a dentist?

4.What treatment was performed?

5.Was the treatment completed?

6.When were dental x-rays taken?

7.Did you have a cleaning ? YES NO

8.Have you had gum (periodontal) treatment? YES NO

9.Have you ever had prolonged bleeding after an extraction? YES NO If yes, please specify:

10.Have you had any problems with past dental treatment? YES NO If yes, please specify:

11.Do you grind your teeth, clinch your jaws, or have symptoms near your ears such as clicking, popping, pain or locking open?

YES NO If yes, please specify:

12.Have you ever been diagnosed or treated for TMD (Temporomandibular Joint Dysfunction) sometimes called TMJ?

YES NO If yes, please specify:

13.Do your gums bleed easily? YES NO

14.Do you feel you have bad breath? YES NO

15.Are your teeth sensitive to hot or cold? YES NO

16.Would you like your teeth whiter? YES NO

YES NO If no, please specify:

1. Are you under a Doctor's care at this time? YES NO

If yes, please specify:

Dr. Name:

Dr. Phone:

2.Are you allergic to penicillin, codeine, local anesthetics, tranquilizers or any other drugs or medicine?

3.Are you taking any medications at this time, including birth control? YES NO

If yes, please specify:

4.(Women) Are you pregnant now? YES NO If yes, how many months?

Are you nursing? YES NO

5.Are there any other health problems of which we should be advised? Please specify: