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About us
Dr. Janice W. Yap
Our team
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Services
Cosmetic dentistry
Teeth whitening
Enamel shaping
Veneers
Bonding
Restorative Dentistry
Preventive Dentistry
Periodontal Care
Endodontic Treatment
Sport Dentistry
GALLERY
CONTACT US
Patient Registration Form
Dental & Medical History Forms
Dental & Medical History Forms
Download PDF for print
DENTAL HISTORY
Patient name
DENTAL HISTORY
Patient Account No.
Medical Alert
Welcome! So that we may provide you with the best possible care please complete both sides of this medical/dental history form. All information is completely confidential.
What is the reason for your visit today?
Date of Last Dental Visit
Last Dental Cleaning
Last Full Mouth X-rays
What was done at your last dental visit?
Previous Dentist's Name
Telephone
Address
State
Zip
How often do you have dental examinations?
How often do you brush your teeth?
How often do you floss?
Have you ever used or are currently using topical fluoride?
Yes
No
What other dental aids do you use? (Interplak, toothpick, etc.)
Do you have any dental problems now?
Yes
No
If yes, please describe:
Are any of your teeth sensitive to:
Hot or cold?
Yes
No
Sweets?
Yes
No
Biting or Chewing?
Yes
No
Have you noticedany mouth odors or bad tastes?
Yes
No
Do you frequently get cold sores, blisters or any other oral lesions?
Yes
No
Do your gums bleed or hurt?
Yes
No
Have your parents experienced gum disease or tooth loss?
Yes
No
Have you noticed any loose teeth or change in your bite?
Yes
No
Does food tend to become caught in between your teeth?
Yes
No
If yes, where?
Do you:
Clench or grind your teeth while awake or asleep?
Yes
No
Bite your lips or cheeks regularly?
Yes
No
Hold foreign objects weeth your teeth? (pencils, pipe, etc.)
Yes
No
Mouth breathe while awake or asleep?
Yes
No
Have tired jaws, especially in the morning?
Yes
No
Snore or have any other sleeping disorders?
Yes
No
Smoke/chew tobacco or use other tobacco products?
Yes
No
Have you ever had:
Orthodontic treatment?
Yes
No
Oral Surgery?
Yes
No
Periodontal treatment?
Yes
No
Your teeth ground or the bite adjusted?
Yes
No
A bite plate or mouth guard?
Yes
No
A serious injury to the mouth or head?
Yes
No
Please describe, including cause
Have you experienced:
Clicking or popping of the jaw?
Yes
No
Pain? (joint, ear, side of face)
Yes
No
Difficulty in opening or closing the mouth?
Yes
No
Difficulty in chewing on either side of the mouth?
Yes
No
Headaches, neckaches or shoulder aches?
Yes
No
Sore muscles (neck, shoulders)?
Yes
No
Are you satisfied with your teeth's appearance?
Yes
No
Would you like to replace your silver fillings?
Yes
No
Would you like to keep all of your teeth all of your life?
Yes
No
Do you feel nervous about having dental treatment?
Yes
No
Please describe
Have you ever had an upsetting dental experience?
Yes
No
Please describe
Have you ever been told to take a pre-medication prior to dental treatment?
Yes
No
Is there anything else about having dental treatment that you would like us to know?
Yes
No
Please describe
MEDICAL HISTORY
MEDICAL HISTORY
1. Physician’s Name
Phone
Have you had any medical care within the past two years?
Yes
No
Describe
2. Have you taken any medication or drugs during the past two years?
Yes
No
If yes, please list name and dosage
3. Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosages of aspirin?
Yes
No
If yes, please list name and dosage
4. Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or other bisphosphonates?
Yes
No
If yes, please list name and dosage
5. Are you aware of having an allergic (or adverse) reaction to any substance or medication?
Yes
No
If yes, please specify
6. Have you been a patient in the hospital during the past five years?
Yes
No
7. Indicate which of the following you have had, or have at present. Check “yes” or “no” to each item.
Heart (Surgery, Disease, Attack)
Yes
No
Chest Pain
Yes
No
Congenital Heart Disease
Yes
No
Heart Murmur
Yes
No
High/Low Blood Pressure
Yes
No
Mitral Valve Prolapse
Yes
No
Artificial Heart (Valve/Pacemaker)
Yes
No
Rheumatic Fever
Yes
No
Arthritis/Rheumatism
Yes
No
Cortisone Medicine
Yes
No
Swollen Ankles
Yes
No
Stroke
Yes
No
Diet (Special/Restricted)
Yes
No
Artificial Joints (hip, knee, etc.)
Yes
No
Kidney Trouble
Yes
No
Ulcers
Yes
No
Diabetes
Yes
No
Thyroid Problems
Yes
No
Glaucoma
Yes
No
Contact lenses
Yes
No
Emphysema
Yes
No
Chronic Cough
Yes
No
Tuberculosis
Yes
No
Asthma
Yes
No
Hay (Fever, Allergy, Hives)
Yes
No
Latex Sensitivity
Yes
No
Sinus Trouble
Yes
No
Radiation Therapy
Yes
No
Chemotherapy
Yes
No
Tumors
Yes
No
Hepatitis (A, B, C)
Yes
No
Venereal Disease
Yes
No
A.I.D.S./H.I.V Positive
Yes
No
Cold Sores/Fever Blisters
Yes
No
Blood Transfusion
Yes
No
Hemophilia
Yes
No
Sickle Cell Disease
Yes
No
Bruise Easily
Yes
No
Liver Disease/Yellow Jaundice
Yes
No
Neurological Disorders
Yes
No
Epilepsy or Seizures
Yes
No
Fainting or Dizzy Spells
Yes
No
Nervous/Anxious
Yes
No
Psychiatric/Psychological Care
Yes
No
Cancer
Yes
No
8. Have you lost or gained more than 10 pounds in the past year?
Yes
No
9. Do you have or have you had any disease, condition, or problem not listed?
Yes
No
10.
Women:
Are you pregnant or think you could be pregnant?
Yes
Months
No
Nursing?
Yes
No
11. Do you use birth control prescriptions?
Yes
No
I understand the above information is necessary to provide me whith 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.
Patient / Guardian Signature
Date
History Review
