MEDICAL AND DENTAL HISTORY

Mrs

Miss

Last Name

First Name

ZIP code

Location

Street Number

Profession

Date of Birth

Social Security Number

Security Company

Complementary Insurance

GSM

Home Phone

Office Phone

Email address

How did you find the office ? (internet, Doctena, friends…)

MEDICAL HISTORY

Your doctor’s last name, address and phone number

When was your last medical examination

Have you experienced any changes in your health in the past year?

Yes

Have you ever had abnormal bleeding during an operation or an accident?

Yes

Have you ever been treated with radiation or chemotherapy?

Yes

Are you currently taking any medication?

Yes

Are you allergic to certain products or medicines?

Yes

Do you smoke?

Yes

Number of cigarretes / day and for how long

Mrs., Miss, are you pregnant?

Yes

How many months

Are you currently taking the pill?

Yes

How many months

Are you under any treatment for osteoporosis or another bone disease ?

Yes

What type of medication are you taking?

Hormones

Estrogens

Biphosphonates

If you think you have any other illness or any other problem not indicated in the list above which could help us treat you in the best conditions, please specify it here

DENTAL HISTORY

When was your last dental examination

What is the reason for your consultation?

During your previous visits to the dentist, have you encountered any particular difficulties ? If so, which?

DENTAL HYGIENE

When do you brush your teeth?

Morning

Afternoon

Evening

How often do you change your toothbrush?

Do you use

Dental Floss

Interdental Brushes

Do you feel like you have a bad breath / bad taste in your mouth?

Yes

GUM

Have you noticed that your teeth have separated after some time?

Yes

Do your gums bleed after brushing your teeth, or even spontaneously?

Yes

Have you ever treated your gums?

Yes

Surgery

Medicines

Descaling

TEETH

Have you ever extracted teeth?

Yes

Have the extracted teeth been replaced?

Yes

A Fixed Bridge

Denture

An Implant

How do you feel with your current prostheses?

Regarding the use of metals in your mouth, do you have any particular preferences?

Yes

If not, for what reason?

If so, which

JAWS

Do you clench or grind your teeth?

Yes

Do you have any cracking, clicking or pain when you open your jaw?

Yes

Do you have difficulty chewing or do you chew frequently only on one side?

Yes

HABITS

Have you had in the past or do you currently have any of the following habits

Thumb sucking

Biting your tongue, lip or cheek

Playing a musical wind instrument

Biting your nails

Chewing pencils, glasses or pens

Crunch ice cubes

AESTHETIC DENTISTRY

In a wide smile, are your teeth all the same color?

Yes

Would you like to have whiter teeth?

Yes

Are you satisfied with your teeth and gum’s appearance?

Yes

Do you put your hand in front of your mouth when you laugh or smile?

Yes

If you had the possibility to change your smile, what would you like change?

VARIOUS

Have you worn any appliance or braces to straighten your teeth?

Yes

What is your main concern regarding your teeth?

Ideally, what would you like to change in your mouth?

Are you anxious about getting dental care?

Not at all

A Little

Moderately

A lot

Other useful or important remarks

Thank you very much for your cooperation.

I certify the accuracy of this document and I have not omitted anything.
I will immediately report any
modification concerning my state of health and my medical prescriptions.

Date

Clear

Patient’s Signature (Or Legal Guardian)