Dental History Questionnaire
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.
Date
*
-
Month
-
Day
Year
Date
Name
*
Prefix
First Name
Initial
Last Name
What is the reason for your visit today? Are you currently experiencing any dental problems?
*
Have you been seeing a dentist regularly? If not, why not?
*
Yes
No
if not, why not?
Are you nervous during dental visits?
*
Yes
No
Not Sure/Maybe
Have you had a bad experience or complications during dental treatment?
*
Yes
No
Not Sure/Maybe
When was your last dental visit? What was done at that appointment?
*
When did you last have dental x-rays?
*
Have you ever seen a dental specialist?
*
Yes
No
Not Sure/Maybe
How often do you brush your teeth? How often do you floss? Do your gums bleed when you brush or floss?
*
Have you been told to take antibiotics before a dental appointment?
*
Yes
No
Not Sure/Maybe
Do you feel that you have bad breath?
*
Yes
No
Not Sure/Maybe
Are you happy with the appearance of your teeth?
*
Yes
No
Not Sure/Maybe
Do you have any problems with your jaw (clicking, limited movement, pain}?
*
Yes
No
Not Sure/Maybe
Have you ever had an injury to the teeth or jaws or been involved in a motor vehicle accident?
*
Yes
No
Not Sure/Maybe
To the best of my knowledge, the above information is correct:
Patient/Parent/Guardian Signature:
*
Date
*
-
Month
-
Day
Year
Date
Internal use only
Dentist Signature:
Date
-
Month
-
Day
Year
Date
Dentist's Notes
Submit
Should be Empty: