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.
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?

YesNo
If yes, please describe
Are you happy with your smile?

YesNo
If yes, please describe
Do you have any dental problems now

YesNo
If yes, please describe
Are any of your teeth sensitive to:

Hot or coldSweetsBiting or ChewingHave you noticed any mouth odors or bad tastes?Do you frequently get cold sores, blisters or any other oral lesions?Do your gums bleed or hurt?Have your parents experienced gum disease or tooth loss?Have you noticed any loose teeth or change in your bite?Have you noticed any odors or bad tastes?Does food tend to become caught in between your teeth?
Have you experienced:

Clicking or popping of the jawPain (joint, ear, side of face)Difficulty in opening or closing the mouthDifficulty in chewing on either side of the mouthHeadaches, neckaches or shoulder achesSore muscles (neck, shoulders)
Have you experienced:

Clicking or popping of the jawPain (joint, ear, side of face)Difficulty in opening or closing the mouthDifficulty in chewing on either side of the mouthHeadaches, neckaches or shoulder achesSore muscles (neck, shoulders)
Have you ever had:

Orthodontic treatmentOral SurgeryPeriodontal treatmentYour teeth ground or the bite adjustedA bite plate or mouth guardA serious injury to the mouth or head
A serious injury to the mouth or head: Please describe, including cause
Do you:

Clench or grind your teeth while awake or asleepBite your lips or cheeks regularlyMouth breathe while awake or asleepHave tired jaws, especially in the morningSnore or have any rther sleeping disordersDo you feel nervous about having dental treatment?Have you ever had an upsetting dental experience?Is there anything else about having dental treatment that you would like us to know?
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: