Dental Health Questionnaire
Patient Name
*
First Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
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2015
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1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
When did you have X-rays last?
/
Month
/
Day
Year
Date
When was your last dental visit?
/
Month
/
Day
Year
Date
When did you last have your teeth cleaned?
/
Month
/
Day
Year
Date
How often do you have your teeth cleaned?
Have you ever had any gum treatment?
Yes
No
If so, what kind and when?
Is there a history of gum disease in your family?
Yes
No
Do you currently have any pain in your mouth?
Yes
No
If so, where and when did it begin?
Do you have a history of frequent abscesses in your mouth?
Yes
No
Do you have bad breath?
Yes
No
Have you ever had any serious problem associated with previous dental treatment?
Yes
No
If yes, please explain:
How often do you brush your teeth?
What type of toothbrush do you use?
Manual
Electric
Both
If electric, what kind?
Sonicare
Oral-B/Braun
Other
What texture of brush do you use?
Soft
Medium
Hard
How often do you floss?
Once per day
Once per week
Once per month
Rarely
Do you use anything else besides a toothbrush and/or floss?
Yes
No
If so, what?
Do your gums bleed when you brush?
Yes
No
Do your gums bleed when you floss?
Yes
No
Do you avoid brushing any part of your mouth because of pain?
Yes
No
If so, what part?
Do your gums feel tender or swollen?
Yes
No
Have you ever had orthodontic treatment?
Yes
No
Who is your orthodontist?
When did you have your braces removed?
Do you still wear a retainer?
Do you clench or grind your teeth together while sleeping or during the day?
Yes
No
Do your jaws ever feel tired?
Yes
No
Do your jaws ever lock open?
Yes
No
Does your bottom jaw click or pop when you open or close?
Yes
No
If so, do you have any pain when this occurs?
Yes
No
Do you have any problem chewing your food?
Yes
No
Have you lost teeth?
Yes
No
Missing teeth replaced by:
Fixed bridge(s)
Implant(s)
Removable partial denture(s)
Removable full denture(s)
Have you discussed replacement(s) with your dentist?
Yes
No
If so, what type of replacement(s) have been discussed?
Fixed bridge(s)
Implant(s)
Removable partial denture(s)
Removable full denture(s)
Do you usually have cavities?
Yes
No
Do you lose fillings or break fillings?
Yes
No
Are you pleased with the appearance of your teeth?
Yes
No
How do you feel about your teeth in general? Is there anything else you feel is important that you would like to share?
Signature
*
Today's Date
*
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Month
-
Day
Year
Date
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