Dental History
Welcome! So that we may provide you with the best possible care, please complete this dental history form. All information is completely confidential.
Patient's Name:
First Name
Last Name
What is the reason for your visit today?
Date of last dental visit:
-
Month
-
Day
Year
Estimated date of last dental cleaning:
-
Month
-
Day
Year
Estimated date of last full mouth x-rays:
-
Month
-
Day
Year
What was done at your last dental visit?
Previous dentists name:
First Name
Last Name
Previous dentists phone number:
Please enter a valid phone number.
How often do you have dental examinations?
How often do you brush your teeth?
How often do you floss your teeth?
Do you use an electric toothbrush?
Yes
No
Have you ever used or are currently using topical fluoride?
Yes
No
Do you have any dental problems now?
Yes
No
If yes, please describe:
Are any of your teeth sensitive to:
Yes
No
Hot or cold
Sweets
Biting or Chewing
Have you noticed any mouth odors or bad tastes
Do you frequently get cold sores, blisters or any other oral lesions
Do your gums bleed or hurt
Have your parents experienced gum disease or tooth loss
Have you noticed any loose teeth or change in your bite
Does food tend to become caught in between your teeth
If yes, where does food get caught?
Do you:
Yes
No
Clench or grind your teeth while awake or asleep
Bite your lips or cheeks regularly
Hold foreign objects with your teeth (pencils, pipe, etc.)
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:
Yes
No
Orthodontic treatment
Oral surgery
Periodontal treatment
Your teeth ground or the bite adjusted
A bite plate or mouth guard
A serious injury to the mouth or head
If yes, please describe injury:
Have you experienced:
Yes
No
Clicking or popping of the jaw
Pain (joint, ear, side of face)
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)
General questions:
Yes
No
Are you satisfied with your teeth's appearance?
Would you like to replace your silver fillings?
Would you like to keep all of your teeth all of your life?
Do you feel nervous about having dental treatment?
Have you ever had an upsetting dental experience?
Have you ever been told to take a pre-medication prior to dental treatment?
Is there anything else about having dental treatment that you would like us to know?
Signature:
Date:
-
Month
-
Day
Year
Submit
Submit
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