Dental History Form- Madison Dentistry

  • Dental History

  • Name Nickname Age  Referred by    How would you rate the condition of your mouth?             Previous Dentist  How long have you been a patient?  Months/Years Date of most recent dental exam   Pick a Date   Date of most recent x-rays   Pick a Date   Date of most recent treatment (other than a cleaning)   Pick a Date   I routinely see my dentist every:                WHAT IS YOUR IMMEDIATE CONCERN?      

  • 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)
  • 2. Have you had an unfavorable dental experience?
  • 3. Have you ever had complications from past dental treatment?
  • 4. Have you ever had trouble getting numb or had any reactions to local anesthetic?
  • 5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
  • 6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?

  • Gum And Bone

  • 7. Do your gums bleed or are they painful when brushing or flossing?
  • 8. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
  • 9. Have you ever noticed an unpleasant taste or odor in your mouth?
  • 10. Is there anyone with a history of periodontal disease in your family?
  • 11. Have you ever experienced gum recession?
  • 12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
  • 13. Have you experienced a burning or painful sensation in your mouth not related to your teeth?

  • Tooth Structure

  • 14. Have you had any cavities within the past 3 years?
  • 15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
  • 16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
  • 17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
  • 18. Do you have grooves or notches on your teeth near the gum line?
  • 19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
  • 20. Do you frequently get food caught between any teeth?

  • Bite And Jaw Joint Questions

  • 21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
  • 22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?
  • 23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
  • 24. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?
  • 25. Are your teeth becoming more crooked, crowded, or overlapped?
  • 26. Are your teeth developing spaces or becoming more loose?
  • 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?
  • 28. Do you place your tongue between your teeth or close your teeth against your tongue?
  • 29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
  • 30. Do you clench or grind your teeth together in the daytime or make them sore?
  • 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?
  • 32. Do you wear or have you ever worn a bite appliance?

  • 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)?
  • 34. Have you ever bleached (whitened) your teeth?
  • 35. Have you felt uncomfortable or self conscious about the appearance of your teeth?
  • 36. Have you been disappointed with the appearance of previous dental work?
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