Dental History Form
Patient Name
*
First Name
Last Name
Nickname
Age
Referred by
How would you rate the condition of your mouth?
Excellent
Good
Poor
Fair
Describe
Previous Dentist
How long have you been a patient?
Months/Years
Date of the most recent dental exam
-
Month
-
Day
Year
Date Picker Icon
Date of most recent X-rays
-
Month
-
Day
Year
Date Picker Icon
Date of most recent treatment (other than a cleaning)
-
Month
-
Day
Year
Date Picker Icon
I routinely see my dentist every
3 mo.
4 mo.
6 mo.
12 mo.
Not routinely
WHAT IS YOUR IMMEDIATE CONCERN?
Please answer "Yes" or "No" to the following
PERSONAL HISTORY
Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)
*
Least
1
2
3
4
5
6
7
8
9
Most
10
1 is Least, 10 is Most
Have you had an unfavorable dental experience?
*
Yes
No
If "Yes" Please Explain
*
Have you ever had complications from past dental treatment?
*
Yes
No
If "Yes" Please Explain
*
Have you ever had trouble getting numb or had any reactions to local anesthetic?
*
Yes
No
If "Yes" Please Explain
*
Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
*
Yes
No
If "Yes" Please Explain
*
Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?
*
Yes
No
If "Yes" Please Explain
*
GUM AND BONE
Do your gums bleed sometimes or are they ever painful when brushing or flossing?
*
Yes
No
If "Yes" Please Explain
*
Have you ever been treated for gum disease, had scaling and root planing, or been told you have lost bone around your teeth?
*
Yes
No
If "Yes" Please Explain
*
Have you ever noticed an unpleasant taste or odor in your mouth?
*
Yes
No
If "Yes" Please Explain
*
Is there anyone with a history of periodontal disease in your family?
*
Yes
No
If "Yes" Please Explain
*
Have you ever experienced gum recession, or can you see more of the roots of your teeth?
*
Yes
No
If "Yes" Please Explain
*
Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
*
Yes
No
If "Yes" Please Explain
*
Have you experienced a burning or painful sensation in your mouth not related to your teeth?
*
Yes
No
If "Yes" Please Explain
*
TOOTH STRUCTURE
Have you had any cavities within the past 3 years?
*
Yes
No
If "Yes" Please Explain
*
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
*
Yes
No
If "Yes" Please Explain
*
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
Yes
No
If "Yes" Please Explain
*
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
*
Yes
No
If "Yes" Please Explain
*
Do you have grooves or notches on your teeth near the gum line?
*
Yes
No
If "Yes" Please Explain
*
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
*
Yes
No
If "Yes" Please Explain
*
Do you frequently get food caught between any teeth?
*
Yes
No
If "Yes" Please Explain
*
BITE AND JAW JOINT
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
*
Yes
No
If "Yes" Please Explain
*
Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?
*
Yes
No
If "Yes" Please Explain
*
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
*
Yes
No
If "Yes" Please Explain
*
In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?
*
Yes
No
If "Yes" Please Explain
*
Are your teeth becoming more crooked, crowded, or overlapped?
*
Yes
No
If "Yes" Please Explain
*
Are your teeth developing spaces or becoming more loose?
*
Yes
No
If "Yes" Please Explain
*
Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
*
Yes
No
If "Yes" Please Explain
*
Do you place your tongue between your teeth or close your teeth against your tongue?
*
Yes
No
If "Yes" Please Explain
*
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
*
Yes
No
If "Yes" Please Explain
*
Do you clench or grind your teeth together in the daytime or make them sore?
*
Yes
No
If "Yes" Please Explain
*
Do you have any problems with sleep (i.e. Restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
*
Yes
No
If "Yes" Please Explain
*
Do you wear or have you ever worn a bite appliance?
*
Yes
No
If "Yes" Please Explain
*
SMILE CHARACTERISTICS
Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size, display)?
*
Yes
No
If "Yes" Please Explain
*
Have you ever bleached (whitened) your teeth?
*
Yes
No
If "Yes" Please Explain
*
Have you felt uncomfortable or self conscious about the appearance of your teeth?
*
Yes
No
If "Yes" Please Explain
*
Have you been disappointed with the appearance of previous dental work?
*
Yes
No
If "Yes" Please Explain
*
Patient Signature
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date Picker Icon
Submit
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