cosmeticsmile.net - Dental History

Dental History
Patient Name
Date of birth

MonthDayYear
Date
Welcome! To ensure we provide you with the highest quality care, please complete both sides of this
medical and dental history form. All information provided will remain strictly confidential
What is the reason for your visit today?
Date of last dental visit?

MonthDayYear
Date
Last Dental Cleaning
Last Full Mouth X-rays
What was done at your last dental visit?
Previous Dentist’s Name
Office Telephone
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How often do you brush your teeth
How often do you floss?
Do you Pre-Medicate?
If yes, please describe
Are you happy with your smile?
If yes, please describe
Do you have any dental problems now
If yes, please describe
Are any of your teeth sensitive to:
Have you experienced:
Have you experienced:
Have you ever had:
A serious injury to the mouth or head: Please describe, including cause
Do you:
Do you feel nervous about having dental treatment? If yes, please describe
Have you ever had an upsetting dental experience? If yes, please describe
Is there anything else about having dental treatment that you would like us to know? If yes, please describe
Should be Empty: