Dental History Update

Patient Information

Patient's Name*

First Middle Last Suffix

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Dental Health (please leave blank if no)

On a scale of 1 – 10, with 10 being the highest rating, where would you rate your current dental health?

What is the most important thing to you about your dental visit today?

Do you smoke or vape or use chewing tobacco?

Yes
No

How much?

How often?

If I could change my smile, I would (please leave blank if no):

Make it brighter
Make it straighter
Close spaces
Repair chipped teeth
Replace missing teeth
Replace old crowns that don’t match
Replace black metal fillings with natural tooth-colored fillings
If you could whiten your teeth for a cost anyone could afford, would you do it?

On a scale of 1 – 10, with 10 being the highest rating, how important is your dental health to you?

What is the most important thing to you about your future smile and dental health?

Medical History Update

Medical History Update (please leave blank if no)

Other:

For WOMEN only (please leave blank if no)

Birth Control Pills
Breast Feeding
Pregnant (1-3 months)
Pregnant (4-6 months)
Pregnant (7-9 months)

Pre-medication

Do you have any of the following allergies? (please leave blank if no)

Aspirin
Codeine
Third Choice
Erythromycin
Latex
Penicillin
Sulfa
Tetracycline

Other Allergies

Are you under a physician’s care? What for?

Are you taking any medications? What?

Have you had any dental insurance changes since your last visit?

Signature

Patient (Parent of Child) Signature:*

First Last

By typing your name, you are certifying that the above knowledge is correct to the best of your knowledge, and is for the professionals at Hammond & Proctor to best meet your dental needs.

Date*