Health History Form

Patient Information

How did you hear about Back Mountain Dental?

DENTAL INSURANCE INFORMATION

Insured is
Are you covered with a second insurance company?

DENTAL INFORMATION Signature of Responsible Party

Do your gums bleed when you brush?

Have you ever had orthodontic treatment?

Do you have headaches, earaches or neck pains?

Have you had any periodontal (gum) treatments?

Do you wear removable/fixed dental appliances?

Are you aware of loose teeth or broken fillings?

Are your gums swollen or tender?

Are you a mouth breather?

Do you or have you been told you grind your teeth?

Do you frequently get blisters on lips or mouth?

Do you ever get a burning sensation on tongue?

Do you have pain when brushing?

Do you chew on one side of mouth?

Do you get clicking or popping of your jaw?

Do you bite your nails or foreign objects?

Do you get jaw pain or tiredness?

Does food collect between your teeth?

Are your teeth sensitive to cold, hot, sweets, or pressure?

Do you have a family history of Periodontal Disease?

Have you been told you have periodontal (gum) disease ?

Have you had any problems associated with previous dental treatment or past dental experiences? If so explain:

Oral habits:

What fluoride products do you use/consume?

What are the three most important factors you desire from your dental office?

Please indicate the level of dental care you would like us to provide:

MEDICAL INFORMATION

Are you in good health?

Have there been any changes in your health within the past year?

Do you consume snacks/beverages containing sugar between meals?

Have you ever had any serious illness, operation, or been hospitalized in the past five years?

What is your alcohol consumption history?

What is your history of tobacco use?
Cigarette, Cigar or Pipe Use

Smokeless Tobacco Use​​​​​​​

Are you taking any medications (Prescription or Over-the-Counter)?

Are you allergic to or have you had a reaction to?

Local Anesthetics

Penicillin or other antibiotics

Barbiturates, sedatives, or sleeping pills

Sulfa Drugs

Codeine or other narcotics

Latex

Iodine

Metal

Please list any drugs or medicines that you cannot or prefer to not take because of allergies or side-effects especially Antibiotics for infections, analgesics for pain, and anesthetics.​​​​​​​

What is your preferred drug for mild and/or severe pain?

What is your preferred antibiotic for an infection?

Please (x) a response to indicate if you have or have had any of the following diseases or problems

Abnormal Bleeding

Controlled? (Circle one):

AIDS or HIV

Anemia

Herpes

Arthritis

Rheumatoid Arthritis

Asthma

Blood Transfusion

If yes, date

Cancer/Chemotherapy/Radiation

Cardiovascular diseases?

Heart Attack Date
Chest Pain/Shortness of breath upon
Chronic Pain
G.E. Reflux, persistent heartburn, or Gastrointestinal Disease
Hemophilia
Hepatitis, Jaundice, or Liver Disease
High / Low Blood Pressure
Recurrent Infection If yes, what type of infection
Diabetes
Fainting spells or seizures
Dry Mouth
Epilepsy
Joint Replacement
Eating disorder
Disease, drug or Radiation-induced immunosuppression
Mental Health disorder
Night sweats/ Menopausal
Neurological disorders
Osteoporosis
Persistent swollen glands
Severe headaches / migraines
Severe or rapid weight loss
Sexually transmitted disease
Sinus Trouble
Sores or ulcers in the mouth
Stroke
Systemic Lupus Erythematous
Tuberculosis
Thyroid problems
Ulcers
Excessive urination thirst
Do you have any disease not listed above? Is there anything else you think we should know about? Please explain:
Have you ever been told you needed to Pre-medicate for dental treatment?
Are you pregnant?
Are you planning to be pregnant?
Please feel free to add any additional information you would like us to know about your medical or dental care:
I certify that I have read and understand the above. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist or any other member of his/her staff responsible for any action they take because of errors or omission that I may have made in the completion of this form.

SMILE EVALUATION

Do you like the appearance of your teeth, your smile?
Do you like the color and shape of your teeth?
Are there old fillings or dental work that you don’t like?
If you could, what would you change about the appearance of your teeth?
Would you like us to tell you about:

I understand that I am financially responsible for care provided and that insurance is considered a method of reimbursement but is not a substation for payment. I authorize my signature to be “on file” for the processing of dental claims on my or my family’s behalf and authorize benefits to be paid directly to Back Mountain Dental, Inc. I understand that deductibles, co-payments and non-covered services are my responsibility to pay at the time of service. A $35 statement fee will be added to any balance over 30 days old.

The highest compliment our patients can give us is the referral of their friends and family. Thank you for your trust!