HELPTAG | Course Authoring | Medical History

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: