Medical History
Mrs.
Miss
Mr.
Dr.
Other











NOTE: These questions are for your benefit. This confidential information will assist us in your diagnosis and treatment.
Check the following that apply to you:
Heart Trouble
Heart Surgery
Heart Valve Prosthesis
Congenital Heart Problems
Heart Murmur
Rheumatic Fever
Stroke
High Blood Pressure
Glaucoma
Stomach Ulcers
Hemophilia
Anemia
Leukemia
Sickle Cell Disease
Kidney Disease
Diabetes
Thyroid Disease
Jaundice
Liver Disease/Hepatitis
Sjogren Syndrome
Hives/Shingles
Sinus Trouble
Asthma
Emphysema
Tuberculosis
Persistent Cough
Epilepsy
Fainting/Dizziness
Herpes/Cold Sores
Sexually Transmitted Disease
AIDS/HIV/HPV
Joint Replacement
Arthritis
Cancer
Chemotherapy
Cortisone Medicine
Blood Transfusion
Psychiatric Care
Drug Dependence
Child Births
Please list all medications or drugs (including aspirin, vitamins, hormones, antacids, steroids, or birth control pills which you are presently taking or have taken in the last six months (including does and frequency):
Has there been any change in your general health in the last year?
NO
      
YES (Please explain.)
Have you been hospitalized, seriously ill, injured or under a doctor’s care during the past two years?
NO
      
YES (Please explain.)
Are you allergic or have your experience an unusual reaction to drugs?
NO
      
YES (Please explain and list.)
Have you experienced excessive bleeding that required special treatment?
NO
      
YES (Please explain.)
Are you required to restrict your diet, work or activities in any way?
NO
      
YES (Please explain.)
Is there a history of Diabetes in your immediate family?
NO
      
YES (Please explain.)
Have you ever been treated for a growth or tumor in any part of your body?
NO
      
YES (Please explain.)
Do you smoke cigarettes, cigars, or pipe?
NO
      
YES (Please explain which, how many per day, and for how long.)
Are you under a great deal of stress on a daily basis, or has your daily stress increased?
NO
      
YES (Please explain.)
Do you have frequent headaches or migraines?
NO
      
YES (Please explain which, the area of the head, and the duration.)
WOMEN: Are you pregnant, nursing, anticipating pregnancy, or experiencing menopausal symptoms?
NO
      
YES (Please explain.)
HAVE WE FORGOTTEN ANYTHING?
Please list any disease, condition or problem (not previously listed) that you feel we should know about:
Dental Health History
Check any of the following which you may have had or experienced:
Injury to Face or Jaw
Slow Healing Mouth Sores
Fever Blisters
Mouth Ulcers
Swollen Gums
Bleeding Gums
Sensitivity to Hot
Sensitivity to Cold
Mouth Odor
Bad Taste in Mouth
Loose Teeth
Change in Bite
Aches to Jaw Joint
Tired Jaw or Sore Muscles
Clicking / Popping Jaw
Jaw Locking – open or closed
Root Canal Therapy
Orthodontic Therapy
Which of the following do you use on a daily basis?
Manual Toothbrush
Type:
Electric Toothbrush
Type:
Mouthrinse
Type:
Waterpik
Proxabrush
Fluoride Rinse
Floss
Are currently experiencing pain in your mouth?
NO
      
YES (Please explain where pain is located.)
How do you feel about keeping your teeth for the rest of your life?
Are you happy with the appearance of your teeth?
If not, what would you change?
Have you had previous periodontal (gum) treatment?
NO
      
YES (Explain what part of your mouth and when.)
Have you had oral surgery?
NO
      
YES (Explain what type and when.)
Have you had crowns and/or bridgework?
NO
      
YES (Explain what part of your mouth and when.)
Have you ever had orthodontic therapy (braces)?
NO
      
YES (Explain when and for how long.)
Have you ever worn a bite guard, bite plane or night guard?
NO
      
YES (Explain if currently being used, and why it was prescribed.)
Have you noticed any change in the position of your teeth?
NO
      
YES (Explain what part of your mouth and when did you notice.)
Do you have difficulty chewing?
NO
      
YES (Explain how or when.)
Is it difficult to open your mouth wide?
NO
      
YES (Explain how or when.)
Are you worried about receiving dental treatment?
NO
      
YES (Explain your concern.)
SLEEP APNEA QUESTIONS
Have you had a sleep study?
NO
      
YES (Please provide ordering physician’s name, and if you were diagnosed with it.)
Please answer the following questions to determine your risk of Sleep Apnea:
Have you ever been told that you snore?
NO
      
YES
Do you have morning headaches?
NO
      
YES
Are you 50 or older?
NO
      
YES
Has your physician ordered you a CPAP device?
NO
      
YES
Are you often tired during the day?
NO
      
YES
Do you have high blood pressure?
NO
      
YES
Are you a male?
NO
      
YES
Do you have breathing issues?
NO
      
YES
Jeffrey M. Cooper, DMD, PA ~ Mark Schmidt, DDS