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803.782.8786
DENTAL HISTORY
What is the reason for your visit today?
Checkup/cleaning
Implant Evaluation
If other, please describe
Date of Last Cleaning
Q 4 - 6 months ago
Q more than 2 years ago
I have recent (within 1-3 years) x-rays at another dental office.
Tooth Ache
Denture Evaluation
Q 6-12 months ago
Previous Dentist's Name, Address, Phone number
How often do you brush your teeth?
Q Once a day Q Twice a day
Orthodontic Evaluation
Q 12 - 24 months ago
Q More than twice a day
Q Occasionally (1-3 times per week)
How often do you floss or use a water flosser (WaterPik)?
Q Never
Q Frequently (more than 4 times per week)
Do you use a toothpaste or mouthwash containing flouride?
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www.columbiadentistry.com 3731 Forest Drive Columbia, SC 29204
Amalgam Removal
Yes No
Lip Enhancement/Dermal Filler Other
Patient Name (print):_________________________Date of Birth:______________
Do you have any dental problems now?
Qves QNo
If yes, please describe:
Are any of your teeth sensitive to:
Hot or Cold Sweets Biting or Chewing
Do you:
Notice any mouth odors or bad tastes?
Frequently get cold sores, blisters, or any other oral lesions?
Experience bleeding or any discomfort in your gums?
Clench or grind your teeth while awake or asleep?
Bite your lips or cheeks regularly?
Hold foreign objects with your teeth?
Mouth breathe while awake or asleep?
Have tired jaws, especially in the morning?
Snore or have any other sleeping disorders?
Smoke/chew tobacco or use tobacco products?
Have you or your parents experienced gum disease or tooth loss?
Have you noticed any loose teeth or change in your bite?
www.columbiadentistry.com
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Forest Drive Dental Care 3731 Forest DriveColumbia, SC 29204 803.782.8786
Patient Name (print):_________________________Date of Birth:______________
Qves
If yes, where does food get caught between your teeth?
Have you ever had:
Orthodontic treatment (braces)?
Periodontal treatment (gum disease)?
A bite plate or mouth guard?
Oral Surgery (extractions)?
Your teeth ground or the bite adjusted?
A serious injury to the mouth or head?
If you have had an injury, please describe, including cause:
Have you experienced:
Clicking or popping of the jaw? Pain? Uoint, ear, side of face)
www.columbiadentistry.com
Difficulty in opening or closing your mouth?
Headaches, neckaches or shoulder aches?
Difficulty in chewing on either side of the mouth?
Please describe:
Are you satisfied with your teeth's appearance?
Qves QNo
If no, please describe
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Forest Drive Dental Care 3731 Forest DriveColumbia, SC 29204803.782.8786
Does food get caught between your teeth?
Patient Name (print):_________________________Date of Birth:______________
Oves
Do you feel nervous about having dental treatment?
Qves
If yes, what is your biggest concern?
Have you had an upsetting dental experience?
Qves
If yes, please describe
Have you ever been told to take a pre-medication (antibiotic) prior to dental treatment?
Oves
If yes, for what for what reason?
Is there anything else about having dental treatment that you would like us to know?
Oves
If yes, please describe
MEDICAL HISTORY
Physician's Name, Address and Phone
www.columbiadentistry.com
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Forest Drive Dental Care 3731 Forest DriveColumbia, SC 29204 803.782.8786
Would you like to keep all of your teeth all of your life?
Patient Name (print):_________________________Date of Birth:______________
Qves
If yes, please describe
Have you taken any prescription or non-prescription drugs in the past 2 years?
www.columbiadentistry.com
If yes, please list names and dosage
Have you ever taken prescription medications for weight loss (diet pills)? Qves QNo
If yes, did you take any of the following?
Fen-Phen Pondimen Redux Other
Have you noticed any sensitivity to metals in jewerly or dental materials?
Qves QNo
Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or other similar drugs?
Qves QNo
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Forest Drive Dental Care 3731 Forest DriveColumbia, SC 29204 803.782.8786
Have you had any medical care or surgeries in the past two years?
Patient Name (print):_________________________Date of Birth:______________
Yes No
Are you currently taking any medications, drugs, pills, vitamins or herbal remedies, including regular dosages of aspirin?
Yes No
www.columbiadentistry.com
Are you aware of having an allergic (or adverse) reaction to any substance or medication?
Qves
If yes, please specify
Have you been a patient in the hospital during the past five years?
Qves QNo
If yes, please describe
Indicate which of the following you have had, or have at present.
Heart (Surgery, Disease, Attack)
Heart Murmur
Artificial HeartValve/Pacemaker
Cortisone Medicine
Diet (Special/Restricted)
Ulcers
Glaucoma
Chronic Cough
Hay Fever/Allergy/Hives
Radiation Therapy
Hepatitis A
Blood Transfusion
Bruise Easily
Epilepsy or Seizures
Chest Pain
High Blood Pressure
Low Blood Pressure
Swollen Ankle
Artificial Joints (hip, knee, etc)
Diabetes
Tuberculosis
Latex Sensitivity
Chemotherapy
Hepatitis B
A.I.D.S/H.I.V Positive
Hemophilia
Liver Disease/Yellow Jaundice
Fainting or Dizzy Spells
Congenital Heart Disease
Mitral Valve Prolapse
Arthritis/Rheumatism
Stroke
Kidney Trouble
Thyroid Problems
Emphysema
Asthma
Sinus Trouble
Tumors
Hepatitis C
Cold Sores/Fever Blisters
Sickle Cell Disease
Neurological Disorders
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Forest Drive Dental Care 3731 Forest DriveColumbia, SC 29204 803.782.8786
Patient Name (print):_________________________Date of Birth:______________
AnxietyPsychiatric/Psychological Care
Rheumatic Fever
Qves
Do you have or have you had any disease, condition, or problem not listed?
Qves
If yes, please list.
www.columbiadentistry.com
Is there anything else you would like us to know about you before your dental visit?
Women: Are you pregnant or think you could be pregnant?
Qves QNo
Are you nursing?
Qves QNo
Do you use birth control prescriptions?
Qves QNo
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.
History Review (for office use only)
Response Date:
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Forest Drive Dental Care 3731 Forest DriveColumbia, SC 29204803.782.8786
Have you lost or gained more than 10 pounds in the past year?
Patient Name Signature Date
Patient Name (print):_________________________Date of Birth:______________
__________________ ___________________________ ____________
