www.westwooddentistryma.com - Dental History

Dental History
Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
RelaxedA little uneasyTenseAnxiousVery Anxious
YesNo
If so, when was your last dental visit?*
How would you rate your previous dental experience?
What are your dental concerns?
YesNo
If so, why have you avoided regular dental care?*
YesNo
If not, why are you unhappy with the appearance of your teeth?*
How often do you brush?
How often do you floss?
How often do you use other aids?
water flosser, gum picks, gum stimulator, etc.
YesNo
YesNo
Do you have, or have you ever had any of the following dental conditions? Please check all that apply.
Aching or sensitive teethAreas of food trapsBroken fillingCavitiesCold soresDry mouthFacial surgeryGrowths or lesions in your mouthGum treatmentsJaw clenchingNight guardOrthodontic treatmentSwelling or lumps in mouthTeeth grindingActive decay of teeth or gumsBad breathBroken or missing teethClicking or popping jawDifficulty opening wideAesthetic concerns with teethGag easilyGum infection / diseaseJaw pain or tirednessLoose teethOral surgerySensitive or bleeding gumsSwollen glandsUnfavorable dental experienceNone of the above
Previous dentist or dental office
Name of previous dentist or dental office
Address of previous dentist or dental office

Street Address

Street Address Line 2

CityState

Zip Code
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in status.
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Dental History

Do you have, or have you ever had any of the following dental conditions? Please check all that apply.