Dental History
Name
*
First Name
Last Name
Purpose of Visit Today?
Have you ever experienced any of the following?
*
My jaw clicks or hurts
I think I grind my teeth
I had orthodontic treatment
I wear a night guard
I have or had gum disease
I had my bite adjusted
I ofter bite my cheeks or lips
Clotting/Bleeding Problems
My mouth often seems dry
I smoke tobacco or use vape regularly
I have or had bad breath
My gums bleed when I brush my teeth
I experience hot.cold sensitivity
The floss tears between my teeth
Food gets stuck between my teeth
My teeth hurt when I bite hard
I have been told that I have deep pockets
Other
Are any of your teeth sensitive or aching right now?
*
Yes
No
If yes, which tooth/area?
When was your last dental visit?
*
When was your last professional cleaning?
*
When was your last X-ray?
*
What is your dental comfort level on a scale from 1 (not comfortable) to 10 (completely satisfied)?
*
How often do you brush your teeth?
*
Floss?
*
Select all that you use
*
Mouthwash
Toothpicks
Proxy-brush
Floss threaders
Are there any concerns related to the health of your gums?
*
Yes
No
If yes, please list:
The following symptoms could indicate TMJ/TMD or bite problems. Please circle any that may apply to you:
Please check any that may apply to you:
*
Back/Neck Pain
Bell's Palsy
Clenching
Difficulty chewing
Difficulty swallowing
Ear congestion
Facial Pain
Grinding
Headaches
Hot/Cold Sensitivity
Insomnia
Joint popping/clicking
Limited opening
Loose teeth
Ringing in ears (Tinnitus)
Tender/sensitive teeth
Tingling in fingertips
TM Joint pain
Trigeminal Neuralgia
Rate your SMILE from 1 to 10? (1 = I hide my smile / 10 = I love my smile)
*
What would you like to change to improve your teeth?
*
Is there anything you want us to know about that has not been covered on this form?
*
Date
-
Month
-
Day
Year
Date
Patient Signature
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