• DENTAL HISTORY

  • Welcome to Asheville Smiles Cosmetic & Family Dentistry! Our mission is simple. We utilize the latest and greatest dental technology to provide world class dental care with hometown heart. Our purpose is to offer meticulous, uncompromising, state of the art dental care with the commitment to honoring and caring for each individual with sovereignty and respect.

    While we may ask a lot of questions on our paperwork, we truly want to serve you with the best dental care we can. Please take the time to answer thoroughly so we can best serve you.

  • How Did You Hear About Us? Check all that Apply:

  • Previous Dental History

  • Last Dental Visit
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  • Last Dental Cleaning
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  • Last Full Mouth Xrays
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  • Format: (000) 000-0000.
  • I routinely see my dentist every:
  • Has a physician or dentist recommended that you take antibiotics prior to dental treatment in the past?

  • Social History

  • Do you use tobacco?
  • Do you drink alcohol?
  • Are you on a special diet?
  • Do you drink lemon water, apple cider vinegar, sports drinks, soda, energy drinks, juice, or other acidic beverages?
  • Date:
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  • PERSONAL DENTAL HISTORY

  • Are you fearful of dental treatment?
  • Have you had an unfavorable dental experience?
  • Have you ever had complications from past dental treatment?
  • Have you ever had trouble getting numb or had any reactions to local anesthetic?
  • Were you born with missing teeth or had teeth that never developed?
  • Do you have any injuries that require you not to be able to lean all the way back in the chair?

  • HOME HABITS

  • How often do you brush your teeth?
  • Do you use an electric toothbrush?
  • Do you floss or Waterpik daily?
  • Is your home water system fluoridated?
  • Do you use fluoride toothpaste?
  • Do you use mouthwash?
  • How often do you change your toothbrush or toothbrush head?

  • GUM AND BONE

  • Do your gums bleed or are they painful when brushing and flossing?
  • Does food or floss catch between your teeth?
  • Have you ever been treated for gum disease or been told you have lost bone around your teeth?
  • Do you have any loose teeth?
  • Have you ever noticed an unpleasant taste or odor in your mouth?
  • Is there anyone in your family with a history of periodontal disease or tooth loss?
  • Have you ever experienced gum recession?
  • Have you experienced a burning or painful sensation in your mouth not related to your teeth?
  • Do you have any sores or ulcers in your mouth?
  • Do you wear dentures?
  • If yes, do you remove your dentures every night?

  • TOOTH STRUCTURE

  • Have you had any cavities within the past 3 years?
  • Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
  • Do you notice or feel any holes in your teeth?
  • Are your teeth sensitive to cold, hot, sweets, or pressure?
  • Are you currently experiencing dental pain or discomfort?
  • Have you ever broken teeth, chipped teeth, or cracked a filling?

  • BITE AND JAW JOINT

  • Do you have problems with your jaw joint? (pain, clicking, limited opening, locking open or shut, or popping)
  • Do you have ear aches or neck pain?
  • Have you had any serious injury to your head, neck or mouth?
  • Do you feel your lower jaw is being pushed back when you try to bite your back teeth together?
  • Do you avoid eating or have difficulty chewing hard crunchy foods?
  • Do you have any grooves or notches on your teeth near the gum line?
  • In the past 5 years, have your teeth changed by becoming shorter, thinner or worn?
  • In the past 5 years, have you noticed changes to your bite?
  • Are your teeth becoming more crooked, crowded or overlapped?
  • Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
  • Do you place your tongue between your teeth or close your teeth against your tongue?
  • Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
  • Do you clench or grind your teeth together in the daytime to make them sore?
  • Do you have any problems with sleep (restlessness or teeth grinding, waking up with a headache, or an awareness of your teeth?
  • Do you wear or have you ever worn a bite appliance?
  • Do you have it with you?
  • Have you ever had orthodontic treatment/braces?

  • SMILE CHARACTERISTICS

  • Is there anything about the appearance of your teeth that you would like to change?
  • Would you like your teeth to be straighter?
  • Have you ever whitened your teeth?
  • Would you like your teeth to be whiter?
  • Have you felt uncomfortable/self-conscious about the appearance of your teeth or smile?
  • Have you been disappointed with the appearance of previous dental work?
  • Is there anything else that you would like to mention to the dental staff here that was not covered in any other question or section?
  • Date:
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  • Should be Empty: