Dental History

Dental History
Name*

First NameLast Name
Purpose of Visit Today?
Have you ever experienced any of the following?*

My jaw clicks or hurtsI think I grind my teethI had orthodontic treatmentI wear a night guardI have or had gum diseaseI had my bite adjustedI ofter bite my cheeks or lipsClotting/Bleeding ProblemsMy mouth often seems dryI smoke tobacco or use vape regularlyI have or had bad breathMy gums bleed when I brush my teethI experience hot.cold sensitivityThe floss tears between my teethFood gets stuck between my teethMy teeth hurt when I bite hardI have been told that I have deep pocketsOther
Are any of your teeth sensitive or aching right now?*

YesNo
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*

MouthwashToothpicksProxy-brushFloss threaders
Are there any concerns related to the health of your gums?*

YesNo
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 PainBell's PalsyClenchingDifficulty chewingDifficulty swallowingEar congestionFacial PainGrindingHeadachesHot/Cold SensitivityInsomniaJoint popping/clickingLimited openingLoose teethRinging in ears (Tinnitus)Tender/sensitive teethTingling in fingertipsTM Joint painTrigeminal 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

MonthDayYear
Date
Patient Signature

Powered by Jotform SignClear
Should be Empty:

Dental History

The following symptoms could indicate TMJ/TMD or bite problems. Please circle any that may apply to you: