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1708 Coit Rd, Suite 290 · Plano, TX 75075
Mon–Thu: 8:00 am – 5:00 pm
Fri - Sun: Closed

(972) 612-3920
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Home
About Us
- Meet the Doctor
- Office & Technology
New Patients
- Insurance and Financing Options
- New Patient Forms
Services
Contact Us

5.0 · Loved by Plano families

Health Questionnaire

Health Questionnaire - Dental

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HEALTH QUESTIONNAIRE

Correct answers to the following questions will allow your dentist to treat you on a more individual basis, providing the care appropriate for your particular needs. Your answers are for our records only and will be considered confidential.

Name

Birth Date

DENTAL HISTORY

Are you having any discomfort at this time?

Yes

No

Have you ever had any serious trouble associated with previous dental treatment?

Yes

No

lf so explain?

Does dental treatment make you nervous?

No

Slightly

Moderately

Extremely

Date of last dental visit

Have you ever been treated for periodontal disease (gum disease, pyorrhea, trench mouth)?

Yes

No

When were you treated?

How often do you brush?

Brush is:

Soft

Medium

Hard

Do you have or have you ever had any of the following?

MOUTH

Bleeding, sore gums

Yes

No

Unpleasant taste/bad breath

Yes

No

Burning tongue/lips

Yes

No

Frequent blisters, lip/mouth

Yes

No

Swelling/lumps in mouth

Yes

No

Ortho treatments (braces)

Yes

No

Biting cheeks/lips

Yes

No

Clicking/popping jaw

Yes

No

Difficulty opening or closing jaw

Yes

No

TEETH

Loose teeth

Yes

No

Sensitive to hot

Yes

No

Sensitive to cold

Yes

No

Sensitive to sweets

Yes

No

Sensitive to biting

Yes

No

Food impaction

Yes

No

Clenching/grinding

Yes

No

If so, when?

Shifting in bite

Yes

No

Change in bite

Yes

No

Do you use the following?

Brush

Yes

No

Dental floss

Yes

No

Fluoride rinse

Yes

No

Other

General Medical Questions

Has there been any change in your general health within the past year?

Yes

No

My last physical examination was on

Are you now under the care of a physician?

Yes

No

If so, what is the condition being treated

The name and address of my physician is

Have you had any serious illness within the past five (5) years

Yes

No

If so, what was the illness

Have you been hospitalized or had an operation within the past five (5) years

Yes

No

If so, what was the problem

Diseases or Problems

Do you have or have you had any of the following diseases or problems?

Yes

No

Rheumatic fever or rheumatic heart disease

Yes

No

Congenital heart disease

Yes

No

Cardiovascular disease (heart trouble, heart attack, heart murmur, coronary insufficiency, coronary occlusion, high/low blood pressure, arteriosclerosis, stroke, etc.)

Do you have pain in chest upon exertion

Yes

No

Are you ever short of breath after mild exercise

Yes

No

Do your ankles swell

Yes

No

Do you get short of breath when you lie down, or do you require extra pillows when you sleep

Yes

No

Artificial or replacement valves

Yes

No

Pacemaker

Yes

No

Allergy

Yes

No

Sinus trouble

Yes

No

Asthma or hay fever

Yes

No

Hives or a skin rash

Yes

No

Fainting spells or seizures

Yes

No

Diabetes

Yes

No

Diabetes follow-up

Do you have to urinate (pass water) more than six times a day

Yes

No

Are you thirsty much of the time

Yes

No

Does your mouth frequently become dry

Yes

No

Do you have or have you had any of the following diseases or problems?

Hepatitis, jaundice or liver disease

Yes

No

Arthritis or inflammatory rheumatism

Yes

No

Artificial or replacement joints, prosthetic

Yes

No

Digestive system - Ulcers or stomach disorders (colitis)

Yes

No

Kidney trouble

Yes

No

Tuberculosis

Yes

No

Persistent cough or cough up blood

Yes

No

Immune System disorders (including AIDS, HIV, ARC)

Yes

No

Other

Bleeding

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, explain the circumstances & when

Medical History

Have you ever tested positive for the AIDS virus?

Yes

No

Do you have any blood disorder such as anemia?

Yes

No

Have you had surgery or x-ray treatment for a tumor, growth, or other condition?

Yes

No

Are you taking any of the following?

Antibiotics or sulfa drugs

Yes

No

Anticoagulants (blood thinners)

Yes

No

Medicine for high blood pressure

Yes

No

Cortisone (steroids)

Yes

No

Tranquilizers

Yes

No

Antihistamines

Yes

No

Aspirin

Yes

No

Insulin, tolbutamide (Orinase) or similar drug for diabetes

Yes

No

Digitalis or drugs for heart trouble

Yes

No

Nitroglycerin

Yes

No

Other medications

Yes

No

If "Yes" to any of the above, state drug name, dosage and frequency

Are you allergic or have you reacted adversely to:

Local anesthetics

Yes

No

Penicillin or other antibiotics

Yes

No

Sulfa drugs

Yes

No

Barbiturates, sedatives, or sleeping pills

Yes

No

Aspirin

Yes

No

Iodine

Yes

No

Codeine or other narcotics

Yes

No

Other

Lifestyle / Other Medical Information

Do you use any tobacco products

Yes

No

If so, how much per day and what

Do you use any alcohol products

Yes

No

If so, how much per day/week/month and what

Do you use any caffeinated products (coffee, tea, chocolate, etc.)

Yes

No

If so, how much per day and what

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

Yes

No

If so, explain

Are you employed in any situation which exposes you regularly to x-rays or other ionizing radiation?

Yes

No

Are you wearing contact lenses

Yes

No

Are you experiencing stress or pressure in your work or at home?

Yes

No

WOMEN

Are you pregnant

Yes

No

Do you have PMS or problems associated with your menstrual period

Yes

No

Are you taking birth control or hormone therapy

Yes

No

Remarks:

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

Signature of Patient

Date

Signature of Dentist

Date

Contact and Appointment FAQ

Where is the office located?

David L. Baker DDS PA is located at 1708 Coit Rd Suite 290, Plano, TX 75075.

Is the building accessible?

The building has accessible parking and elevator access.

Can I contact the office after hours?

Yes. The main phone number routes after-hours communication through text messaging.

What areas does the office serve?

The office primarily serves Plano and nearby areas, including North Dallas, Carrollton, Allen, and Richardson.

Comfortable, personalized family dentistry in Plano, Texas caring for the same neighborhood for over three decades.

Explore

Meet the Doctor
Office & Technology
New Patient Forms
Insurance and Financing Options
Contact Us
Pay Your Bill

Meet the Doctor
Office & Technology
New Patient Forms
Insurance and Financing Options
Contact Us
Pay Your Bill

Services

Dental Cleaning and Examinations
Dental Crowns & Composite Fillings
Dental Implants & Procedure
Dentures and Partial Dentures

Dental Cleaning and Examinations
Dental Crowns & Composite Fillings
Dental Implants & Procedure
Dentures and Partial Dentures

Visit

(972) 612-3920
1708 Coit Rd, Suite 290
Plano, TX 75075
Mon–Thu: 8:00 am – 5:00 pm
Fri - Sun: Closed

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