Welcome to pediatricdentistryofburke.com

Do you have any concerns about your mouth, teeth, or oral health? Yes
No If Yes, describe:

Have you recently experienced any dental/oral pain? Yes
No If Yes, describe:

Do you have any concerns with the appearance of your teeth or smile? Yes
No If Yes, describe:

Do you bleach your teeth? Yes
No If Yes, describe:

Have there been any recent changes in your dietary habits? Yes
No If Yes, describe:

Are you taking any dietary or herbal supplements? Yes
No If Yes, describe:

Do you participate in contact sports or high speed sports (sliding, motorcycles)? Yes
No If Yes, describe:

Oral habits (chewing fingernails, clenching/grinding teeth, etc.) Yes
No
Prefer Not To Answer

Toabacco use (cigarette, pipe, cigar, bidi, snuff, spit, chew, etc.) Yes
No
Prefer Not To Answer

Eating disorder (anorexia, bulimia, etc.) Yes
No
Prefer Not To Answer

Oral piercings/Jewelry (including grill) Yes
No
Prefer Not To Answer

Alcohol or recreation drug use/prescription abuse Yes
No
Prefer Not To Answer

Inhalant use/abuse (such as huffing) Yes
No
Prefer Not To Answer

Sexual activity (including oral sex) Yes
No
Prefer Not To Answer

Females: Are you pregnant or possibly pregnant? Yes
No

Is there anything you would like to discuss confidentially with your dentist? Yes
No

Would you like to discuss a referral to a family dentist or general dentist because of your age? Yes
No

Supplemental History Questions For an Adolescent Patient