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Reason for visit
Date of last dental visit/
Date of last dental x-rays
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Physician/Clinic Phone or Location
Pharmacy
Pharmacy Phone
How often do you brush?
How often do you floss?
Do you smoke or use tobacco products?
Please list any medication you are now taking *It is especially important to know if you are taking bone/osteoporosis medications (Fosamax,Boniva, Prolia, Reclast, or Actonel) tranquilizers, phenobarbital or dilantin, blood thinners (aspirin, Warfarin/Coumadin, Plavix, Xarelto, Eliquis), steroid medicines, nitroglycerin, arthritis or thyroid medicine.
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Are you pregnant? If yes, # of weeks
Are you nursing?
YesNo Are you having pain or discomfort now? If so, what? YesNo Do your gums bleed when you brush? YesNo Have you had periodontal or gum treatment? YesNo Have you had any undesirable treatment experience? If so, what? YesNo Do you have any sores or lumps in your mouth that don’t heal? YesNo Are you unhappy with your smile? If so, why? YesNo Have you had orthodontic treatment? YesNo Are you currently under a physician’s care? If so, for what? YesNo Have you had any illness or surgery in the past year? If so, what? YesNo Are you changing dentists for any particular reason? If so, why?
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