Dental History Form

Please circle the appropriate answer for each condition/disease.

1. Have you had any serious problem(s) with any previous dental treatment?

Yes No

2. Have you ever had an injury to your face, jaw, or teeth?

Yes No

3. Do you ever feel like you have a dry mouth?

Yes No

4. Have you ever had an unusual reaction to local anesthetic (numbing)?

Yes No

5. Do you wear full or partial dentures?

Yes No

6. Have you had any teeth replaced with a dental implant(s)?

Yes No

7. Have you had any teeth replaced with a fixed bridge(s)?

Yes No

9. Do you have any piercings in the head and neck area?

Yes No

Have you ever had any Lip, Jaw or Gum Augmentation (fillers)?

Yes No

10. Do you smoke or use tobacco in any form?

Yes No

The answers to the questions listed above are accurate. I understand this information will be used to determine the dental treatment I receive in this dental office and may be shared with other medical offices only as necessary. I will notify this dental office should any information change. I hereby authorize this dental office to perform recommended services.

Patient Signature: ( Note :Signature is Required * )

Clear Signature

Doctor Signature:( Note :Signature is Required * )

Clear Signature

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