19613 W 101st Street, Lenexa, KS 66220 Steven Blum, DDS
913.390.5110Fax 913.390.5664
Patient Full Name:______Birth Date: ______
Dental history
Please check the appropriate boxes if you currently have, or have experienced:
□ Tooth sensitivity hot, cold, or sweets
□ Tooth pain when chewing or biting
□ Cracked or Chipped teeth
□ Bleeding gums, How long? ______
□ Pain or soreness in gums
□ Food impaction
□ Unpleasant taste or breath odor
□ Swelling, infection or bumps in mouth
□ Loose teeth
□ Clenching or grinding
□ Jaw joint soreness / pain around the ear area
□ Clicking or popping in the joint when eating
□ Burning tongue
□ Previous orthodontic (braces) treatment
□ Wear a removable dental appliance
□ Mouth breathing or Dry mouth
□ Do you snore?
□ Sleepy throughout the day while working, driving or reading. Persistent tiredness.
□ Have you had a sleep study?
□ Oral habits (nail biting, cheek biting, etc)
□Dental anxiety
□ Any bad experiences in a dental office?
______
Dates of Last Dental Exam______Gum Disease Screening______Oral Cancer Screening______
What is the primary purpose of today’s visit? Any concerns?______
______
How important is your dental health to you? 1 2 3 4 5 6 7 8 9 10
Where would you rate your current dental health? 1 2 3 4 5 6 7 8 9 10
How would you rate the appearance of your smile? 1 2 3 4 5 6 7 8 9 10
If not a 10, please describe what you would want to improve: ______
______
How often do you brush your teeth? ______
Do you use an Electric Toothbrush? ______
What other dental aids do you use?
□Floss
□Mouth rinse, which one ______
□Water Pik
□Other______
What treatments are you interested in learning about?
□Orthodontics (braces) or Clear Braces
□Implants (replacing missing teeth)
□Dentures or Partial Dentures
□Sedation (anxiety-free sleep dentistry)
□Gum Disease Treatments
□Cosmetic Dentistry or Veneers
□TeethWhitening
□Sleep Apnea treatments
□Denture Stabilization
□Athletic Mouth Guards or Bite Guards
Please turn over and complete other side. Thank You.
Medical History
Are you being treated by a physician now?______For what?______
Date of last Physical Exam?______
Name of Physician______Address______
Physician’s Phone______City ______
My Pharmacy of Choice: ______Phone # ______
Have you been hospitalized in the last 5 years? For what?______
Have you experienced:
YesNoChest pain (angina)
YesNoSwollen ankles
YesNoRecent weight loss, fever, night sweats
YesNoPersistent cough, coughing up blood
YesNoBleeding problems, bruising easily
YesNo Sinus problems
YesNoDifficulty swallowing
YesNoDiarrhea, constipation, blood in stools
YesNoFrequent vomiting or nausea
YesNoDifficulty urinating, blood in urine
Do you have or have you had:
YesNoFrequent Dizziness
YesNoRinging or Pain in ears
YesNoFrequent Headaches
YesNoBlurred vision
YesNoSeizures
YesNoExcessive thirst
YesNoFrequent urination
YesNoDry mouth
YesNoJaundice
YesNoJoint pain, stiffness, arthritis
YesNoHeart disease, or attack
YesNoHeart murmur
YesNoRheumatic fever
YesNoHeart Valve problems
YesNoStroke, Stentor hardening of arteries
YesNoProsthetic Heart Valve
YesNoHigh blood pressure
YesNoHigh Cholesterol
YesNoPacemaker
YesNoDiabetes
YesNoAsthma
YesNoEmphysema, COPD, Lung disorders
YesNoTuberculosis
YesNoKidney, Bladder or Liver Disease
YesNoHepatitis A, B, or C
YesNoStomach problems, ulcers, colitis
YesNoThyroid or Adrenal Disease
YesNoDepression, or Anxiety Disorders
YesNoAutism, Schizophrenia, psychiatric care
YesNoTumors or Cancer
YesNoRadiation or Chemotherapy treatments
YesNoAlzheimers or Dementia
YesNoParkinson’s or Neuromuscular Diseases
YesNoHIV Positive
YesNoAIDS
YesNoEye diseases or glaucoma
YesNoSleep Apnea
YesNoSkin diseases
YesNoAnemia
YesNoVenereal Disease
YesNoCanker Sores or Cold Sore/Fever Blister
YesNoHospitalization
YesNoBlood transfusions
YesNoAntibiotic pre-med prior to dental care
YesNoArtificial Joint or replacement
surgeries: ______
Allergies to medications, latex, food______
Are you taking?
YesNoTobacco in any form
YesNoAlcohol
YesNoRecreational Drugs
YesNoDo you use Antacids
YesNoConsume grapefruit or grapefruit extract
YesNoBisphosphonates (for Osteoporosis / Bone) such as: Fosomax, Boniva, Actonel, Zometa, or Aredia?
Please List All Current Medications (prescription, and over-the-counter) and all Supplements______
______
Women Only:
YesNoAre you pregnant or nursing
YesNoHave you had a hysterectomy
YesNoTaking birth control or hormone pills
YesNoTaking fertility drugs
ALL PATIENTS:
YesNoDo you have or have you had any other diseases or medical problems NOT listed on this form?
If so, please explain______
To the best of my knowledge, I have answered every question completely and accurately, I will inform my dentist of any changes in my health and/or medication.
PATIENT SIGNATURE:______DATE:______