Dental History Form- Madison Dentistry

Dental History
Name Nickname Age Referred by How would you rate the condition of your mouth? Excellent Good Fair Poor Previous Dentist How long have you been a patient? Months/Years Date of most recent dental exam Date Date of most recent x-rays Date Date of most recent treatment (other than a cleaning) Date I routinely see my dentist every: 3 mo. 4 mo. 6 mo. 12 mo. Not routinely WHAT IS YOUR IMMEDIATE CONCERN? Type a label
PLEASE ANSWER YES OR NO TO THE FOLLOWING:
Personal History
1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)

YesNo
On a scale of 1 to 10
2. Have you had an unfavorable dental experience?

YesNo
If yes, please describe
If No, please type in "No"
3. Have you ever had complications from past dental treatment?

YesNo
If yes, please describe
If No, please type in "No"
4. Have you ever had trouble getting numb or had any reactions to local anesthetic?

YesNo
If yes, please describe:
If No, please type in "No"
5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?

YesNo
If yes, please describe
If No, please type in "No"
6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?

YesNo
If yes, please describe
If No, please type in "No"
Gum And Bone
7. Do your gums bleed or are they painful when brushing or flossing?

YesNo
If yes, please describe
If No, please type in "No"
8. Have you ever been treated for gum disease or been told you have lost bone around your teeth?

YesNo
If yes, please describe
If No, please type in "No"
9. Have you ever noticed an unpleasant taste or odor in your mouth?

YesNo
If yes, please describe:
If No, please type in "No"
10. Is there anyone with a history of periodontal disease in your family?

YesNo
If yes, please describe
If No, please type in "No"
11. Have you ever experienced gum recession?

YesNo
If yes, please describe
If No, please type in "No"
12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?

YesNo
If yes, please describe
If No, please type in "No"
13. Have you experienced a burning or painful sensation in your mouth not related to your teeth?

YesNo
If yes, please describe
If No, please type in "No"
Tooth Structure
14. Have you had any cavities within the past 3 years?

YesNo
If yes, please describe
If No, please type in "No"
15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

YesNo
If yes, please describe
If No, please type in "No"
16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?

YesNo
If yes, please describe
If No, please type in "No"
17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?

YesNo
If yes, please describe
If No, please type in "No"
18. Do you have grooves or notches on your teeth near the gum line?

YesNo
If yes, please describe
If No, please type in "No"
19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?

YesNo
If yes, please describe
If No, please type in "No"
20. Do you frequently get food caught between any teeth?

YesNo
If yes, please describe
If No, please type in "No"
Bite And Jaw Joint Questions
21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

YesNo
If yes, please describe
If No, please type in "No"
22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?

YesNo
If yes, please describe
If No, please type in "No"
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?

YesNo
If yes, please describe
If No, please type in "No"
24. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?

YesNo
If yes, please describe
If No, please type in "No"
25. Are your teeth becoming more crooked, crowded, or overlapped?

YesNo
If yes, please describe
If No, please type in "No"
26. Are your teeth developing spaces or becoming more loose?

YesNo
If yes, please describe
If No, please type in "No"
27. 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?

YesNo
If yes, please describe
If No, please type in "No"
28. Do you place your tongue between your teeth or close your teeth against your tongue?

YesNo
If yes, please describe
If No, please type in "No"
29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?

YesNo
If yes, please describe
If No, please type in "No"
30. Do you clench or grind your teeth together in the daytime or make them sore?

YesNo
If yes, please describe
If No, please type in "No"
31. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?

YesNo
If yes, please describe
If No, please type in "No"
32. Do you wear or have you ever worn a bite appliance?

YesNo
If yes, please describe
If No, please type in "No"
Smile Characteristics Questions
33. Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size, display)?

YesNo
If yes, please describe
If No, please type in "No"
34. Have you ever bleached (whitened) your teeth?

YesNo
If yes, please describe
If No, please type in "No"
35. Have you felt uncomfortable or self conscious about the appearance of your teeth?

YesNo
If yes, please describe
If No, please type in "No"
36. Have you been disappointed with the appearance of previous dental work?

YesNo
If yes, please describe
If No, please type in "No"
Patient’s Signature

Clear
Date

MonthDayYear
Doctor’s Signature

Clear
Date

MonthDayYear
Should be Empty:

Dental History

PLEASE ANSWER YES OR NO TO THE FOLLOWING:

Personal History

Gum And Bone

Tooth Structure

Bite And Jaw Joint Questions

Smile Characteristics Questions