Health History Form — The Practice SF

Please check anything that applies to you, now or in the past.

My gums bleed when I brush or flossMy gums, teeth or mouth are soreI get mouth infections or sores on my lipsI have a bad taste or odor in my mouthI have been told I have gum diseaseI have had gum treatmentI have had orthodontic treatmentMy teeth have become loose or have driftedI have had gum boils or abscessesI have discomfort opening, biting or chewingMy jaw makes popping or clicking noisesI clench or grind my teethThe appearance of my mouth troubles meI have had complications with dental treatmentI have had injuries or trauma to my jaw or teeth

Cleaning Aids You Use

FlossToothpicksWater irrigatorProxabrush / interdental brush

How Would You Rate Your Health?

ExcellentGoodFairPoor

I have been under a physician's care in the past 2 yearsI have been hospitalized in the past 5 yearsI have had excessive bleeding that was difficult to stopI or an immediate family member has had diabetesI have had a reaction to a local or general anestheticI have lost or gained more than 10 lbs in the past yearI have had excessive thirst or dry mouthI need to urinate frequentlyI heal slowly or bruise easily

I am pregnantI am planning to become pregnantI am undergoing or have undergone menopauseI take hormone pills or shots (including birth control)

In the last 12 months, I have taken medicine for:

In the last 12 months, I have taken:

Heart & circulation — have you ever had:

Heart diseaseHeart surgeryShortness of breath with mild exercise or when lying downSwelling of ankles or feetPain, pressure or tightness in the chest (angina)

Have you ever had any of the following?