Dental History Form

Dental History Form
Patient Name
Date of Birth

MonthDayYear
Date
Date of Last Dental Visit?

MonthDayYear
Date
Reason for the Visit?
Date of Last Dental X-rays?

MonthDayYear
Date
Former Dentist
Phone (Former Dentist)
Address (Former Dentist)

Address

Street Address Line 2

CityState

Zip
If you left your previous dentist, what was the reason?
What are your goals in coming to our practice today?
What is important to you in a dentist or dental practice?
At-Home Oral Hygiene Care
How often do you brush your teeth?
How often do you floss?
Do you use mouth wash? If YES, which kind
Circle Appropriate Answer (Leave blank if you do not understand the questions)
Are you currently experiencing dental pain or discomfort?

YesNo
If YES, explain
Do your gums bleed?

YesNo
If YES, explain
Are your teeth loose?

YesNo
If YES, explain
Do you wear dentures or partials?

YesNo
If YES, explain
Have you ever been told you have gum disease?

YesNo
If YES, explain
Are your teeth sensitive to hot, cold, sweets or pressure?

YesNoOther
Have your ever had any clicking, popping or discomfort in the jaw?

YesNo
Do you brux or grind your teeth?

YesNo
Do you wear an occlusal guard?

YesNo
Have you ever had orthodontic treatment (braces) before?

YesNo
Do you have dry mouth?

YesNo
Does food or floss catch between your teeth?

YesNo
Have you had any problems or an upsetting dental experience associated with previous dental care?

YesNo
If YES, explain
Are you fearful of dentistry or have anxiety associated with dental treatment?

YesNo
If YES, explain
Have you ever been pre-medicated for dental treatment?

YesNo
If YES, explain
Have you ever had a reaction to anesthetic used with your dental treatment?

YesNo
If YES, explain
Are you happy with your smile?

YesNo
If NO, explain
What would you change about the present condition of your mouth?
Is there anything else you would like us to know about your dental health or dental history?

YesNo
If YES, explain
I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful dental history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction.
Signature of Patient (Parent or Guardian)

Clear
Date

MonthDayYear
Date
Should be Empty:

Dental History Form

At-Home Oral Hygiene Care