Complete Patient Past and Current Dental History Form Complete Patient Past and Current Dental History Form Date(Required) MM slash DD slash YYYY Patient's name:(Required) First Last Last dental Hygiene visit or check up:When was your last dental check-up/ hygiene visit? If unsure, ask our receptionist if done at this office PAST AND PRESENT DENTAL HISTORYPlease check YES or NO. To unclick a single box, click the box again and it will unclick. If after reading the next section below in its entirety and all the answers are no, instead of checking each "NO" box just jump to the end of this section and answer "No to All"Are any of your teeth becoming loose? YES NO Are you suffering from pain now? YES NO Have any of your teeth shifted? YES NO Does food get caught between your teeth? YES NO Is there any swelling or pain in your gums? YES NO Are you aware of sores/growths in your mouth? YES NO Is there a history of gum disease in your family? YES NO Have you had a local anesthetic (freezing)? YES NO ....any complications? YES NO Have you had any teeth extracted? YES NO ....any complications? YES NO NS Do you have the burning sensation of lips or tongue? YES NO Does your mouth tend to get dry? YES NO Do you have a bad taste in your mouth or bad breath? YES NO Do you notice any bleeding from your gums when you brush your teeth or others? YES NO Are you nervous about having dental treatment? YES NO If you have read all the above questions and the answer is no to all, please check the box below: No to all of the questions in the above section ONLY ORAL HYGIENEPlease check YES or NO. if not sure, please check NS. To unclick a single box, click the box again and it will unclick. Do you use any fluoride/mouth rinses? YES NO Do you use Dental aids such as proxy brushes, water flossers, dental picks etc.? YES NO Are you happy with the appearance of your teeth? YES NO What would you like to change about your teeth? How often do you brush your teeth? How often do you floss your teeth? JAW PROBLEMS Do you have any of the following below? Pain (in jaw joints - ear, side of the face)? YES NO Clicking/popping of jaw when opening/closing? YES NO Difficulty in opening or closing your mouth? YES NO Pain and/or difficulty in chewing? YES NO Are you being followed-up by a dental specialist? YES NO Pain when cleaning your teeth? YES NO Have you ever had implant surgery in one or both of your jaw joints? YES NO If yes, who performed the surgery and when was it done? TREATMENTS Please check off the following treatments you have had: Oral surgery? YES NO Orthodontic treatment (braces)? YES NO Teeth ground or bite adjusted? YES NO Periodontal treatment (gum surgery)? YES NO Worn a bite plate or other appliance? YES NO Dental implants? YES NO HABITS/ SENSITIVITYDo you clench or grind your teeth while asleep? YES NO NOT SURE Do you breathe through your mouth while awake or asleep? YES NO NOT SURE Do you bite your lips or cheeks regularly? YES NO NOT SURE Are any teeth sensitive to: ( Please check any boxes below if applicable Cold Hot Biting Pressure Sweet Is there anything else you would like us to know? GENERAL CONSENT STATEMENT I certify that I have read, understood, and accurately completed the personal, medical, and dental histories, to the best of my knowledge, and have not knowingly omitted any information. This information has been reviewed with me, and I have had the chance to ask questions and to receive answers regarding any medical and dental histories. As may be required, I consent to my physician being contacted regarding any specific medical question. I authorize the dentist to perform necessary diagnostic procedures and treatment, including general or local anesthetic, as required, to achieve the proper level of dental care. I understand that I am financially responsible to the dentist for the dental services provided even if my insurance coverage may not be all-inclusive. I know that your office has a privacy code, and I can ask to see the code at any time. I agree that your office can collect, use and disclose personal information about me as set out in your office privacy policy. Name of the Patient: Full Name If the patient is a minor or other: Name of the guardian (if applicable): Full Name Relationship to the patient: Signature(Required)Reset to re-sign.Date(Required) MM slash DD slash YYYY
Forestwood Dentistry, Richmond Hill DentistsForestwood Dentistry, Richmond Hill Dentists