GENERAL DENTAL HISTORY
Date of last Dental Exam:
Current Problem/Reason for visit:
Gums Bleeding when Brushing or flossing:
Cold Sensitivity:
Heat Sensitivity:
Sweet Sensitivity:
Biting Sensitivity:
History of orthodontic treatment: yes/no
History of periodontal treatment: yes/no
History of tooth loss: yes/no
Problems/Issues with previous treatments:
Headaches:
Earaches:
Neck pain:
Current Health:
Any change in health condition in the last year:
Currently under Physician Care: Yes/No (if yes, describe)
Current Medications (prescription or OTC):
Currently taking Vitamins or Diet supplements:
Any Orthopedic replacements:
Any Allergies:
Known heritable conditions?:
WOMEN ONLY:
Pregnant: y/n
Nursing: y/n
Taking Birth Control:
Hormone Treatment:
Other current/relevant medical issues or historical considerations:
