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Medical & Dental History Form
⏱
Takes 8-10 minutes to complete
Patient safety is our
number one
priority. Please take your time when completing this form, answering the questions carefully and to the best of your ability.
When was your most recent dental check-up?
(Required)
0 – 3 months ago
3 – 6 months ago
6 – 12 months ago
12+ months ago
Not sure
When was your most recent cleaning / hygienist appointment?
(Required)
0 – 3 months ago
3 – 6 months ago
6 – 12 months ago
12+ months ago
Not sure
When did you most recently have dental x-rays taken?
(Required)
0 – 3 months ago
3 – 6 months ago
6 – 12 months ago
12+ months ago
Not sure
How frequently do you visit the dentist?
(Required)
Every 6 months
Every 12 months
Not routinely
How frequently do you visit the hygienist?
(Required)
Every 6 months
Every 12 months
Not routinely
Are you afraid of visiting the dentist, or of receiving dental treatment?
(Required)
Yes
No
Have you ever had an unfavourable dental experience?
(Required)
Yes
No
Have you ever had complications from past dental treatment?
(Required)
Yes
No
Have you ever had trouble with (or reactions to) local anaesthetic?
(Required)
Yes
No
Have you ever have braces, orthodontic treatment or have your bite adjusted?
(Required)
Yes
No
Have you had any of your adult teeth removed?
(Required)
Yes
No
Have you ever had any root canal treatment or dental implants?
(Required)
Yes
No
Have you ever had composite bonding?
(Required)
Yes
No
2 of 6
Your smile
Is there anything about the appearance of your teeth that you would like to change?
(Required)
Yes
No
2 of 6
Your smile
Have you ever whitened (bleached) your teeth?
(Required)
Yes
No
2 of 6
Your smile
Are you self-conscious about your teeth?
(Required)
Yes
No
2 of 6
Your smile
Have you been disappointed with the appearance of previous dental work?
(Required)
Yes
No
3 of 6
Bite & jaw
Do you (or would you) have any problems chewing gum?
(Required)
Yes
No
3 of 6
Bite & jaw
Do you (or would you) have any problems chewing crusty bread or other hard foods?
(Required)
Yes
No
3 of 6
Bite & jaw
Have your teeth changed in the last 5 years, become shorter, thinner or worn?
(Required)
Yes
No
3 of 6
Bite & jaw
Are your teeth crowding or developing spaces?
(Required)
Yes
No
3 of 6
Bite & jaw
Do you have more than one bite, or do you clench (squeeze) to make your teeth fit together?
(Required)
Yes
No
3 of 6
Bite & jaw
Do you have any problems with sleep or wake up with an awareness of your teeth?
(Required)
Yes
No
3 of 6
Bite & jaw
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
(Required)
Yes
No
3 of 6
Bite & jaw
Do you have tension headaches or sore muscles?
(Required)
Yes
No
3 of 6
Bite & jaw
Do you wear (or have you ever worn) a bite appliance?
(Required)
Yes
No
3 of 6
Bite & jaw
Do you ever grind your teeth when sleeping?
(Required)
Yes
No
3 of 6
Bite & jaw
Do you have a spouse or partner who has noticed any teeth grinding?
(Required)
Yes
No
3 of 6
Bite & jaw
Do you ever wake up with headaches or tenderness in your facial muscles?
(Required)
Yes
No
4 of 6
Tooth structure
Have you had any cavities in the past 3 years?
(Required)
Yes
No
4 of 6
Tooth structure
Do you ever experience a dry mouth?
(Required)
Yes
No
4 of 6
Tooth structure
Are any teeth sensitive to hot / cold / sweet sensations?
(Required)
Yes
No
4 of 6
Tooth structure
Have you ever had a tooth ache, a cracked or damaged filling, or a broken, chipped or cracked tooth?
(Required)
Yes
No
4 of 6
Tooth structure
Do you avoid brushing any part of your mouth?
(Required)
Yes
No
4 of 6
Tooth structure
Do you feel or notice any holes (i.e. pitting) in your teeth?
(Required)
Yes
No
5 of 6
Gum & bone health
Have you ever been diagnosed or treated for periodontal (gum) disease?
(Required)
Yes
No
5 of 6
Gum & bone health
Have you ever experienced gum recession?
(Required)
Yes
No
5 of 6
Gum & bone health
Is there anyone with a history of periodontal disease in your family?
(Required)
Yes
No
5 of 6
Gum & bone health
Do your gums bleed when brushing, flossing or eating?
(Required)
Yes
No
5 of 6
Gum & bone health
Are your teeth becoming loose?
(Required)
Yes
No
5 of 6
Gum & bone health
Have you ever noticed an unpleasant taste or odour in your mouth?
(Required)
Yes
No
5 of 6
Gum & bone health
Have you experienced a burning sensation in your mouth?
(Required)
Yes
No
6 of 6
Medical history
Do you have any history of the following?
(Required)
Thyroid Disease
Heart Disease
Rheumatoid Arthritis
Epilepsy
Asthma
Diabetes
None of the above
6 of 6
Medical history
Are you currently taking steroids?
(Required)
Yes
No
6 of 6
Medical history
Are you currently taking aspirin or any other blood thinners?
(Required)
Yes
No
6 of 6
Medical history
Any allergies? (particularly latex, rubber or local anaesthetic)
(Required)
Yes
No
6 of 6
Medical history
Could you currently be / are you pregnant?
(Required)
Yes
No
6 of 6
Medical history
Are you currently breastfeeding?
(Required)
Yes
No
Patient details
Patient's Forename
(Required)
Patient's Surname
(Required)
Date of Birth
(Required)
DD slash MM slash YYYY
Patient details
Email address
(Required)
Mobile number
(Required)
Patient details
Home address
(Required)
Home address 2
Home address 3
Home address 4
Postcode
(Required)
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