Dr. Nils Bengtson, DDS, MS | General Dentistry

Mouth

Bleeding, sore gums
Unpleasant taste/bad breath
Burning tongue, lips
Frequent blisters, lip/mouth
Swelling/lumps in mouth
Ortho treatments (braces)
Biting cheeks/lips
Clicking/popping jaw
Difficulty opening or closing jaw

Teeth

Loose teeth
Sensitive to hot
Sensitive to cold
Sensitive to sweets
Sensitive to biting
Food impaction
Clenching/grinding If so, when
Shifting in bite
Change in bite

Has there been any change in your general health within the past year? Yes No
When was the date of your last physical examination? Your physician's name Your physician's address Have you been hospitalized or had an operation within the past 5 years? Yes No If so, what was the problem?

Have you started any new medications? Yes No
Are you currently under the care of a physician? Yes No If so, what condition are you being treated for? Have you had any serious illness within the past 5 years? Yes No If so, what was the illness?

Heart disease
High blood pressure
Kidney disease
Mental illness
Migraine
Miscarriage
Muscular Dystrophy
Obesity
Osteoporosis
Stroke
Ulcers

Do you have or have you ever had any of the following diseases or problems? Check all that apply.

Herpes
Glaucoma
Headaches
Diabetes Do you have to urinate more than 6 times a day? Yes No Are you thirsty most of the time? Yes No Does your mouth frequently become dry? Yes No
Hepatitis, jaundice, or liver disease
Arthritis or inflammatory rheumatism
Artificial or replacement joints, prosthetic, including heart valve
Digestive system - ulcers or stomach disorders (colitis)
Kidney trouble
Tuberculosis
Persistent cough or coughing up blood
Immune system disorders including AIDS, HIV, ARC
Venereal disease

Have you had abnormal bleeding associated with previous extractions, surgery, or trauma? Yes No
Do you bruise easily? Yes No
Have you ever required a blood transfusion? Yes No If so, please explain
Do you wear contact lenses? Yes No

Have you ever tested positive for the AIDS virus? Yes No
Do you have any blood disorders such as anemia? Yes No
Have you had surgery or x-ray treatment for a tumor, growth, or other condition? Yes No
Are you employed in any situation which exposes you regularly to x-rays or other ionizing radiation? Yes No
Are you experiencing stress or pressure in your work or home? Yes No

Antibiotics or sulfa drugs
Anticoagulants (blood thinners)
Medicine for high blood pressure
Cortisone (steroids)
Tranquilizers
Antihistamines

Aspirin or other medications such as advil, motrin, aleve, ibuprofen
Insulin, tolbutamide (Orinase), or similar medication for diabetes
Digitalis or medication for heart trouble
Nitroglycerin
Other medication including, herbal, holistic, or vitamins
If you selected any of the above, please list the medication name, dosage, and frequency:

Are you allergic or have you reacted adversely to any of the following? Check all that apply.

Local anesthetics
Penicillin or other antibiotics
Sulfa drugs
Barbituates, sedatives, or sleeping pills
Other

Aspirin
Iodine
Codeine or other narcotics
Latex

Tobacco products What type? How much per day?
Caffeinated products (coffee, tea, chocolate, etc.) What type? How much per day?

Alcohol products What type? How much per day?

Are you pregnant? Yes No
Are you nursing? Yes No
Are you taking birth control or hormone therapy? Yes No

Do you have PMS or problems associated with your period? Yes No
Are you menopausal or post-menopausal? Yes No

Do you have any disease, condition, or problem not listed above that you think your dentist should know about?

To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any changes in my health or changes in my medication,
I will inform the dentist at my next appointment.

Health Questionnaire

Mouth

Teeth