Dental History Form
General Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Who was your previous dentist and how long were you a patient there?
*
Date of your last dental exam
-
Month
-
Day
Year
Date
Date of your last cleaning
-
Month
-
Day
Year
Date
Do you have any immediate concerns you’d like us to address?
Office Relationship
What do you value most in your dental visits?
Is there anything you prefer during your visits to make you more comfortable during your time with us?
On a scale from 1-5, how fearful are you of dental treatment?
*
Least Fearful
1
2
3
4
Most Fearful
5
1 is Least Fearful, 5 is Most Fearful
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Personal History
Please answer the following questions
Are you concerned about the appearance of your teeth?
*
Yes
No
Are you interested in improving your smile?
*
Yes
No
Have you had any cavities within the past 2 years?
*
Yes
No
Are any teeth currently sensitive to biting, sweets, hot, or cold?
*
Yes
No
Do you avoid or have difficulty chewing or biting heavily any hard foods?
*
Yes
No
Do you have any problems sleeping, wake up with a headache or with sore orsensitive teeth?
*
Yes
No
Do you clench your teeth in the daytime?
*
Yes
No
Do you wear, or have you ever worn a bite appliance? Either for clenching at night (a night guard) or for sleep apnea?
*
Yes
No
Do you bite your nails, chew gum or on pens, hold nails with your teeth, or any other oral habits?
*
Yes
No
Does the amount of saliva in your mouth seem too little or do you find yourself with a dry mouth often?
*
Yes
No
Have you ever noticed a consistently unpleasant taste or odor in your mouth?
*
Yes
No
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Dental Structure History
Please answer the following questions
Do your gums bleed when brushing or flossing?
*
Yes
No
Is brushing or flossing typically painful?
*
Yes
No
Have you ever experienced or been told you have gum recession?
*
Yes
No
Have you ever been treated for or been told you have gum disease?
*
Yes
No
Have you had any teeth removed for braces or otherwise?
*
Yes
No
Do you know of any missing teeth or teeth that have never developed?
*
Yes
No
Have you ever had braces, orthodontic treatment or spacers, or had a "bite adjustment?"
*
Yes
No
Are your teeth becoming more crowded, overlapped, or "crooked?"
*
Yes
No
Are your teeth developing spaces?
*
Yes
No
Do you frequently get food caught between any teeth?
*
Yes
No
Have you noticed your teeth becoming shorter, thinner, or flatter over the years?
*
Yes
No
Do you have problems with your jaw joint? (TMD, popping, clicking, deviating from side to side when opening or closing?)
*
Yes
No
Is it often difficult to open wide?
*
Yes
No
Do you have more than one bite? Or do you notice shifting your jaw around to make your teeth fit together?
*
Yes
No
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Confirmation
Patient's Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Submit
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