DENTAL HISTORY
Patient Name
Patient Account No.
Medical Alert
What is the reason for your visit today?
Date of Last Dental Visit
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Last Dental Cleaning
Last Full Mouth X-rays
What was done at your last dental visit?
Previous Dentist's Name
How often do you have dental examinations?
How often do you brush your teeth?
How often do you floss?
Have you ever used or are currently using topical fluoride?
Yes
No
How your gums bleed?
Yes
No
What other dental aids do you use? (Interplak, toothpick, etc.)
Do you have any dental problems now?
Yes
No
If yes, Please describe:
Do you:
Rows
Yes
No
Clench or grind your teeth while awake or asleep?
Hold foreign objects with your teeth?(pencils, pipe, pins, nails, fingernails)
Mouth breathe while awake or asleep?
Have tired jaws, especially in the morning?
Snore or have any other sleeping disorders?
Smoke/chew tobacco or use other tobacco products?
Have you ever had:
Rows
Yes
No
Orthodontic treatment?
Oral Surgery?
Periodontal treatment?
Your teeth ground or the bite adjusted?
A bite plan or mouth guard?
A serious injury to the mouth or head?
Yes
No
If so, please describe, including cause
Have you experienced:
Rows
Yes
No
Clicking or popping of the jaw?
Difficulty in opening or closing the mouth?
Difficulty in chewing on either side of the mouth?
Headaches, neckaches, or shoulder aches?
Sore muscles(neck, shoulders)?
Are you satisfied with your teeth's appearance?
Yes
No
Would you like to keep all of your teeth all of your life?
Yes
No
Do you feel nervous about having dental treatment?
Yes
No
If so, what is your biggest concern?
Have you ever had an upsetting dental experience?
Yes
No
If yes, please describe:
Have you ever been told to take a pre-medication prior to dental treatment?
Yes
No
Is there anything else about having dental treatment you would like us to know?
Yes
No
If yes, Please describe:
Submit
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