www.siouxcitydentist.com - Dental History

  • DENTAL HISTORY

  • How would you rate the condition of your mouth?*
  • Date of most recent dental exam
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  • Date of most recent x-rays
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  • Date of most recent treatment (other than a cleaning)
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  • I routinely see my dentist every

  • PLEASE ANSWER YES OR NO TO THE FOLLOWING

  • PERSONAL HISTORY

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

  • GUM AND BONE

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

  • TOOTH STRUCTURE

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

  • BITE AND JAW JOINT

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

  • SMILE CHARACTERISTICS

  • Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size, display)? *
  • Have you ever whitened (bleached) your teeth?*
  • Have you felt uncomfortable or self conscious about the appearance of your teeth?*
  • Have you been disappointed with the appearance of previous dental work?*
  • Date*
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  • Should be Empty: