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Date of Birth:
Birth defects or hereditary problems? Bone fractures or major injuries?Any injuries to face, head, neck? Arthritis or joint problems? Endocrine or thyroid problems? Diabetes or low sugar?Kidney problems?Cancer, tumor, radiation treatment or chemotherapy?Immune system problems?History of osteoporosis?Gonorrhea, syphilis, herpes, sexually transmitted diseases? AIDS or HIV positive?Hepatitis, jaundice, or other liver problems?Polio, mononucleosis, tuberculosis, pneumonia?Seizures, fainting spells, neurologic problems?Mental health disturbance or depression?Vision, hearing, or speech problems?History of eating disorder (anorexia, bulimia)?High or low blood pressure?Excessive bleeding or bruising, anemia?Chest pain, shortness of breath, tire easily, swollen ankles? Heart defects, heart murmur, rheumatic heart disease? Angina, arteriosclerosis, stroke or heart attack?Skin disorder (other than common acne)?Do you eat a well-balanced diet?Frequent headaches or migraines?Frequent ear infections, colds, throat infections?Asthma, sinus problems, hayfever?Tonsil or adenoid condition?Do you frequently breathe through your mouth?Stomach ulcer, hyperacidity, acid reflux?
Local anesthetics (novocaine, lidocaine, xylocaine) Latex (gloves, balloons)AspirinMetals (jewelry, clothing snaps)PenicillinOther antibioticsIbuprofen (Motrin, Advil)AcrylicsPlant pollensAnimalsFoods
Permanent or extra (supernumerary) teeth removed?Supernumerary (extra) or congenitally missing teeth? Chipped or injured primary or permanent teeth? Any sensitive or sore teeth?Bleeding gums, bad taste or mouth odor?Jaw fractures, cysts, infections?Any teeth treated with root canals or pulpotomies? “Gum boils,” frequent canker sores or cold sores? History of speech problems or speech therapy?Food impaction between the teeth? Mouth breathing habit or snoring at night?Teeth causing irritation to lip, cheek or gums? Abnormal swallowing (tongue thrust)? Tooth grinding or clenching?Clicking, locking in jaw joints?Soreness in jaw muscles or face muscles?Have you ever been treated for “TMJ” or “TMD” problems?Any serious trouble associated with previous dental treatment?Have you ever been diagnosed with gum disease or pyorrhea?Have you ever had an orthodontic consultation or treatment before now?Difficulty breathing through the nose?Frequent oral habits (sucking finger, chewing pencil, etc)?Ringing in ears, difficulty chewing or opening jaw?Any broken or missing teeth?
Do you take antibiotic pre-medication before any dental procedures?
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Do you or have you ever had a substance abuse problem?
Do you chew or smoke tobacco?
Have you noticed any changes in your face or jaws?
(Women) Are you pregnant?
Are you trying to become pregnant?
Have your parents or siblings ever had any of the following health problems?
Bleeding disordersArthritisUnusual dental problemsDiabetesSevere allergiesJaw size imbalance
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