Vlahos Dental History Questionnaire

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*

MonthDayYear
Date
Name*

PrefixFirst NameInitial 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?*

YesNo
if not, why not?
Are you nervous during dental visits?*

YesNoNot Sure/Maybe
Have you had a bad experience or complications during dental treatment?*

YesNoNot 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?*

YesNoNot 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?*

YesNoNot Sure/Maybe
Do you feel that you have bad breath?*

YesNoNot Sure/Maybe
Are you happy with the appearance of your teeth?*

YesNoNot Sure/Maybe
Do you have any problems with your jaw (clicking, limited movement, pain}?*

YesNoNot Sure/Maybe
Have you ever had an injury to the teeth or jaws or been involved in a motor vehicle accident?*

YesNoNot Sure/Maybe
To the best of my knowledge, the above information is correct:
Patient/Parent/Guardian Signature:*

Clear
Date*

MonthDayYear
Date
Internal use only
Dentist Signature:

Clear
Date

MonthDayYear
Date
Dentist's Notes
Should be Empty:

Dental History Questionnaire

To the best of my knowledge, the above information is correct:

Internal use only