MODmouth Dental and Health History

First Name:
Last Name:
Email:
Approximate date of last dental cleaning and checkup visit:
Approximate date of last dental Full mouth Xrays:
Were you diagnosed with any cavities, gum disease, bone abnormalities, root problems (such as short roots), or impacted teeth at this visit or in the past?
YesNo
If Yes please state what was diagnosed and note this was treated and resolved prior to visiting us today:
Do you have missing adult teeth?
YesNo
If yes, have you had them replaced with bridges or implants?
Do you clench or grind your jaws while sleeping or during the day?
YesNo
Do your jaws ever feel tired or sore?
YesNo
Do you wear any nighttime sleep appliances?
YesNo
If so, explain:

GENERAL HEALTH HISTORY

General health (please check):
EXCELLENTGOODFAIRPOOR
Are you now under the care of a physician?
YesNo
If Yes please describe what is being treated:
Name of physician:
Are you pregnant or do you think you may be pregnant?
YesNo

MEDICAL HISTORY

Diabetes
YesNo
AIDS/HIV
YesNo
Hepatitis
YesNo
Cold sores/Fever blisters
YesNo
Are you allergic to any drug, material or food?
YesNo
If yes, please explain:
* Your signature indicates you have reviewed and filled out this medical history accurately and received a copy of the HIPAA law and Dental Materials forms and release our office to utilize any dental photographs for lecturing and educational purposes.
Date:
Signature:

Clear