Dental History
Date of last visit
-
Month
-
Day
Year
Date
Name
First Name
Last Name
General Dentist
General Dentist Phone
Please enter a valid phone number.
Format: (000) 000-0000.
General Dentist Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Personal History
1. Are you fearful of dental treatment?
Yes
No
If yes, How fearful, on a scale of 1 (least) to 10 (most)
2. Have you had an unfavorable dental experience?
Yes
No
3. Have you ever had complications from past dental treatment?
Yes
No
4. Have you ever had trouble getting numb or had any reactions to local anesthetic?
Yes
No
5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
Yes
No
6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?
Yes
No
7. Do you have difficulty breathing through your nose?
Yes
No
8. Any type of tongue or thumb habit?
Yes
No
Bite And Jaw
9. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
Yes
No
10. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?
Yes
No
11. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
Yes
No
12. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?
Yes
No
13. Are your teeth becoming more crooked, crowded, or overlapped?
Yes
No
14. Are your teeth developing spaces or becoming more loose?
Yes
No
15. 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?
Yes
No
16. Do you place your tongue between your teeth or close your teeth against your tongue?
Yes
No
17. Do you clench or grind your teeth together in the daytime or make them sore?
Yes
No
18. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
Yes
No
19. Do you wear or have you ever worn a bite appliance?
Yes
No
Smile Characteristics
20. Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?
Yes
No
21. Have you felt uncomfortable or self conscious about the appearance of your teeth?
Yes
No
22. Have you been disappointed with the appearance of previous dental work?
Yes
No
Gums
23. Do your gums bleed or are they painful when brushing or flossing?
Yes
No
24. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
Yes
No
Patient / Guardian’s Signature
Date
-
Month
-
Day
Year
Date
Doctor’s Signature
Date
-
Month
-
Day
Year
Date
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