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DENTAL HEALTH QUESTIONNAIRE
We request payment at the time of service.
If there is a reason why this may be difficult for you at this time, please mention it in advance to the receptionist. Thank you.
These questions are important for your welfare. If your immune system is depressed, then the necessary antibiotic therapy must be more stringent than if your immune system is healthy. Please help us to provide you with the best dental care humanly possible. If you have any questions, please ask the dentist.
___________________________________________________________ ________ ________ ________ _______ ________ _______________________ _________ _________________________________ ______________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________ NAME OF EMPLOYER INSURANCE IS CARRIED WITH _________________________________________________________________________________________________________________________________________________________ It is important that we know about your dental and medical history. Many things have a direct bearing
on your dental health. We will review the questionnaire and discuss it with you in detail. Information
you give us is strictly confidential and will not be released to anyone without your written permission.
1. The name and address of my physician is _____________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________ 2. My last physical examination was on __________________________________________________________________________________________________ 3. Has there been any change in your general health within the past year . YES NO 4. Are you now under the care of a physician . YES NO a. if so, what is the condition being treated ____________________________________________________________________________________________ 5. Have you been hospitalized or had a serious illness within the past five (5) years . YES NO a. if so, what was the problem _______________________________________________________________________________________________________ 6. Please circle any illnesses you have ever had: hepatitis, jaundice or liver disease artificial joints 7. Have you had abnormal bleeding associated with previous extractions, surgery, or trauma . YES NO 8. Do you have any blood disorder such as anemia . YES NO Have you had surgery or x-ray treatment for a tumor, growth, or other condition of your mouth or lips . YES b. Anticoagulants (blood thinners) . YES c. Medicine for high blood pressure . YES h. Insulin, tolbutamide (Orinase) or similar drug . YES i. Digitalis or drugs for heart trouble . YES k. Other _________________________________________________________________________________________________________________________ 12. Are you allergic or have you reacted adversely to: b. Penicillin or other antibiotics . YES d. Barbiturates, sedatives or sleeping pills . YES h. Other _________________________________________________________________________________________________________________________ 13. Have you ever had serious trouble associated with any previous dental treatment . YES If so explain ______________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ 14. Do you have any disease, condition, or problem not listed above . YES If so explain ______________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________ YOUR DENTAL HISTORY
Are you have any discomfort at this time? ________________________________________________________________________________________________ How long since you have been to the dentist? ________________________________________ Why? _____________________________________________ What was done then? __________________________________________________________________________________________________________________ Are your teeth sensitive to hot, cold, or sweets? ___________________________________________________________________________________________ How often do you brush? _______________________________________________________________________________________________________________ How often do you floss? ________________________________________________________________________________________________________________ Do your gums bleed? __________________________________________________________________________________________________________________ Have you ever had gum treatments? _____________________________________________________________________________________________________ Do you grind, grit, or clench your teeth? __________________________________________________________________________________________________ Do you have any popping, clicking, or snapping noise when you chew? ______________________________________________________________________ Are you aware of any swelling, lumps, or sores in your mouth? ______________________________________________________________________________ What is the name and address of your previous dentist? ____________________________________________________________________________________ Why did you leave your previous dentist? _________________________________________________________________________________________________ _________________________________________________________ _________________________________________________________ DENTAL HEALTH QUESTIONNAIRE
Name __________________________________________________________________ Date ____________________ The following questions are very important to you and the dentist and his staff. These questions are intended
for therapeutic reasons only, and the answers are confidential, however, they may be shared with subsequent
treating dentists or physicians.
HIV (AIDS)
1. a. Have you ever tested positive for HIV? . YES NO
b. Do you have any reason to believe that you are at risk of being HIV positive? . YES NO c. Have you ever “shot up” drugs? . YES NO d. Have you ever had sex with a man or woman who has “shot up” drugs? . YES NO 3. Have you ever tested positive for tuberculosis . YES NO b. Results ____________________________________________________________________________________ ___________________________________________________________________________________________ These questions are important for your welfare. If your immune system is depressed, then the necessary anti-biotic therapy must be more stringent than if your immune system is healthy. Please help us provide you with the best dental care humanly possible. If you have any questions, please ask the dentist.
Signed _____________________________________ Dentist _______________________________________ Date _____________________________________ MEDICAL HISTORY UPDATES
I have read my MEDICAL HISTORY and confirm that it adequately states past and present conditions.
__________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________ __________________________________ _____________________

Source: http://www.lexingtondentist.biz/PDFs/29946-AFDC_Dental_Health_Questionnaire.pdf