DENTAL HISTORY
Patient Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Previous Dentist (name & location)
*
Date of last visit
*
-
Month
-
Day
Year
Date
Date of last dental X-rays
*
-
Month
-
Day
Year
Date
What was done at your last dental visit?
How often were you getting your teeth cleaned?
Are you in pain today?
Yes
No
Location
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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
Bite fingernails
Chew ice
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
Loose teeth
Tartar build-up (calculus deposits)
Bad breath
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
Clenching teeth
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
TMJ surgery
How often do you brush?
How often do you floss?
How would you rate your current dental health?
Poor
Fair
Good
Excellent
What type of tooth brush do you currently use?
Manual
Electric
What type of bristles?
Soft
Med
Hard
OTHER: Please write down any other dental history we should be aware of, including surgeries or negative dental experiences
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PATIENTS UNDER 7 YEARS OF AGE
Yes
No
Please describe:
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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