Riverview Medical Health History

Patient Name

Age

Referred by

Previous Dentist's name

How long?

Date of most recent dental exam

Date

I see my Dentist

3 Months 6 Months 12 Months Other Not Routinely

What is your immediate concern?

On a scale of 1-10 (10 greatest), how important is your dental health?

On a scale of 1-10 (10 greatest), how would you rate your current dental health?

On a scale of 1-10 (10 greatest, how fearful are you of dental treatment?

1. Have you had an unfavorable dental experience?

Yes No

2. Have you ever had complications from past dental treatment?

Yes No

3. Have you ever had trouble getting numb or had any reactions to local anesthesia?

Yes No

4. Do you have, or have you had any teeth removed or teeth that never developed?

Yes No

5. Did you ever have orthodontic treatment, braces, or your bite adjusted?

Yes No

6. Do your gums bleed or do they hurt during brushing/flossing?

Yes No

7. Have you ever been told you have gum disease or are losing bone around your teeth?

Yes No

8. Have you ever noticed an unpleasant taste/smell in your mouth?

Yes No

9. Does anyone in your family have a history of periodontal/gum disease?

Yes No

10. Have you experienced gum recession (teeth look longer)?

Yes No

11. Have you ever had any teeth become loose on their own?

Yes No

12. Have you had any cavities within the past 3 years?

Yes No

13. Does the amount of your saliva in your mouth seem to little or do you have trouble eating/swallowing food?

Yes No

14. Do you feel or notice any holes on the tops of your teeth?

Yes No

15. Are your teeth sensitive to hot, cold, biting, sweets, etc or do you avoid brushing any area?

Yes No

16. Do you have grooves or notches on your teeth near the gum line?

Yes No

17. Have you ever broken, chipped, cracked any teeth or had a toothache?

Yes No

18. Do you get food caught between your teeth?

Yes No

19. Do you have problems with your jaw joint? (pain, popping, cracking, locking, etc.)

Yes No

20. Do you avoid chewing gum, carrots, nuts, hard or chewy foods?

Yes No

21. Have your teeth changed in the last 5 years, become shorter, thinner or worn?

Yes No

22. Are your teeth becoming more crooked, crowded, or overlapped?

Yes No

23. Are your teeth developing spaces or becoming loose?

Yes No

24. Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together?

Yes No

25. Do you clench your teeth during the day or night or wake with a headache?

Yes No

26. Do you wear, or have you ever worn, a bite appliance?

Yes No

27. Is there anything about your appearance of your teeth that you would like to change?

Yes No

28. Have you ever whitened/bleached your teeth?

Yes No

29. Have you felt uncomfortable or self-conscious about the appearance of your teeth?

Yes No

30. Have you been disappointed with the appearance of previous dental work?

Yes No

Patient Signature *

Clear

Date

Today

Date

Medical Health History

Dental History Form

Personal History

Gum/Bone History - Periodontal

Tooth Structure History - Cavities

Occlusion History - Bite, Jaw & TMJ

Cosmetic History - Smile