Complete Patient Past and Current Dental History Form

Date(Required)

When was your last dental check-up/ hygiene visit? (If you cannot recall the exact date or year, please approximate in months or years).

PAST & PRESENT PATIENT DENTAL HISTORY:

For the following sections below, please check YES or NO. To unclick a single box, click the box again and it will unclick.

If after reading each 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"

ORAL HYGIENE

Please check YES or NO. if not sure, please check NS. To unclick a single box, click the box again and it will unclick.

If the answer is yes above, what would you like to change about your teeth?

How often do you brush your teeth daily?

How often do you floss your teeth?

JAW PROBLEMS

Do you have any of the following below?

If yes, who performed the surgery and when was it done?

TREATMENTS

Please check off the following treatments you have had:

HABITS & SENSITIVITIES

Is there anything else you would like us to know about your dental history or current dental health that you care to elaborate on?

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.

Relationship to the patient (if applicable):

Signature of Patient or Guardian(Required)

Date(Required)