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.
How do you feel about dental treatment?
Have you seen a dentist before?
If so, when was your last dental visit?
How would you rate your previous dental experience?
What are your dental concerns?
Have you avoided regular dental care?
If so, why have you avoided regular dental care?
Are you happy with the appearance of your teeth?
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.
Would you like your teeth to be whiter?
Would you like your teeth to be straighter?
Do you have, or have you ever had any of the following dental conditions? Please check all that apply.
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
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Dental History