Date of Birth
Previous Dentist (name & location)
Date of last visit
Date of last dental X-rays
What was done at your last dental visit?
How often were you getting your teeth cleaned?
Are you in pain today?
FOR DENTAL PATIENTS OVER THE AGE OF 7
DENTAL SYMPTOMS: please check if you have any of the following:
Chew on one side of mouth
Cracked or broken teeth/fillings
Sensitivity when biting
Sensitivity to hot
Sensitivity to cold
Sensitivity to sweets
Sensitivity when brushing
Unhappy with the appearance of your teeth
HABITS: please check if you do any of the following:
Smoke cigarettes, pipes or cigars
Use smokeless tobacco
Drink more than 12 ounces of soda, juice, sports drinks, orflavored coffee each day
PERIODONTAL SYMPTOMS: please check if you have any of the following:
Bleeding gums with brushing and/or flossing
Swollen or tender gums
Tartar build-up (calculus deposits)
Food collection between teeth
Diagnosis of gum disease (periodontal disease)
Deep cleanings at a previous dental office
TMJ (Temporomandibular Joint): please check if you have any of the following:
Clicking or popping jaw
Grinding teeth at night
Pain or tiredness in jaw or jaw muscles
Pain around ear
Headache or pain in jaw on awakening
Unable to open wide
Unable to close jaw
Night Guard (and wear it nightly!)
Treatment for TMJ disorder
How often do you brush?
How often do you floss?
How would you rate your current dental health?
What type of tooth brush do you currently use?
What type of bristles?
OTHER: Please write down any other dental history we should be aware of, including surgeries or negative dental experiences
PATIENTS UNDER 7 YEARS OF AGE
Has your child been to the dentist before?
Has your child had dental x-rays?
How often does your child brush and floss their teeth?
Does your child receive help brushing and flossing?
Does your child have a source of fluoride other than toothpaste?
Does your child get a bottle or nurse at night?
Does your child have any habits such as thumb sucking or pacifier?
Have you or your spouse had any serious dental problems?
Please describe anything else about your child you feel we should know:
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