Dr. Nakasuka Dental History v.2

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 NameLast Name
What is the reason for your visit today?
Date of last dental visit:

MonthDayYear
Estimated date of last dental cleaning:

MonthDayYear
Estimated date of last full mouth x-rays:

MonthDayYear
What was done at your last dental visit?
Previous dentists name:

First NameLast Name
Previous dentists phone number:
Please enter a valid phone number.Format: (000) 000-0000.
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?
Have you ever used or are currently using topical fluoride?
Do you have any dental problems now?
If yes, please describe:

Are any of your teeth sensitive to:

Rows	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

Do you:

Rows	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:

Rows	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

Have you experienced:

Rows	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:

Rows	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:

MonthDayYear
Should be Empty: