Patient’s Name
Nickname
Patient's Birth Date
-
Month
-
Day
Year
Date
Age:
Referred By:
Previous Dentist:
How long had you been a patient at your last Dental Office:
Date of most Recent Dental Exam
-
Month
-
Day
Year
Date
Date of most Recent Dental X-rays?
-
Month
-
Day
Year
Date
Date of most Recent Treatment (other than Cleaning)?
-
Month
-
Day
Year
Date
How would you rate the condition of your mouth?
Excellent Good
Fair Poor
How long have you been a patient?
Previous Dentist
I routinely see my dentist every:
3 mo.
4 mo.
6 mo.
12 months
Not routinely
WHAT IS YOUR IMMEDIATE CONCERN?
PLEASE ANSWER YES OR NO TO THE FOLLOWING:
Personal History
Are you fearful of dental treatment?
yes
no
Have you had an unfavorable dental experience?
Yes
No
Have you ever had complications from past dental treatment?
Yes
No
Have you ever had trouble getting numb or had any reactions to local anesthetic?
Yes
No
Did you ever have braces, orthodontic treatment or had your bite adjusted?
Yes
No
Have you had any teeth removed?
Yes
No
Do your gums bleed or are they painful when brushing or flossing?
Yes
No
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
Yes
No
Have you ever noticed an unpleasant taste or odor in your mouth?
Yes
No
Is there anyone with a history of periodontal disease in your family?
Yes
No
Have you ever experienced gum recession?
Yes
No
Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
Yes
No
Option 1
Option 2
Option 3
Have you had any cavities within the past 3 years?
Yes
No
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
Yes
No
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
Yes
No
Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?
Yes
No
Do you have grooves or notches on your teeth near the gum line?
Yes
No
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
Yes
No
Do you frequently get food caught between any teeth?
Yes
No
Bite and Jaw Joint
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
Yes
No
Do you feel like your lower jaw is being pushed back when you bite your teeth together?
Yes
No
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
Yes
No
Have your teeth changed in the last 5 years, become shorter, thinner or worn?
Yes
No
Are your teeth becoming more crooked, crowded, or overlapped?
yes
No
Are your teeth developing spaces or becoming more loose?
yes
No
Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together?
Yes
No
Do you place your tongue between your teeth or rest your teeth against your tongue?
Yes
No
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
Yes
No
Do you clench your teeth in the daytime or make them sore?
Yes
No
Do you have any problems with sleep (ie restlessness), wake up with a headache or an awareness of your teeth?
Yes
No
Do you wear or have you ever worn a bite appliance?
Yes
No
Smile Characteristics
Is there anything about the appearance of your teeth that you would like to change?
Yes
No
Have you ever whitened (bleached) your teeth?
Yes
No
Have you felt uncomfortable or self conscious about the appearance of your teeth?
Yes
No
Have you been disappointed with the appearance of previous dental work?
Yes
No
Patient’s Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: