Dental History
How would you rate the condition of your mouth?
*
Excellent
Good
Fair
Poor
Previous Dentist:
Date of most recent dental exam:
-
Month
-
Day
Year
Date
I routinely see my dentist every
03 mo
04 mo
06 mo
12 mo
When I have pain or discomfort
You were recommended-Referred by:
Reason for changing dentist:
Change of residence
Your office is closer
Unhappy experience
Change of dental Plan
My dentist retired or closed
Too expensive
What is your immediate concern?
Ckeck-Up
Pain
Cleaning
Other
I am interested in:
Teeth whitening
Cosmetic consultation
Replace missing teeth
Strengthen teeth
Improve gums
Breath control
Pain relief
Sedation
Other
Personal History—Have you ever:
Been pre-medicated with antibiotics before dental treatment?
Yes
No
Had complications from past dental treatment?
Yes
No
Had trouble getting numb or had any reactions to local anesthetic?
Yes
No
Are you fearful of dental treatment?
Yes
No
How fearful,on a scale of 1 (least)to 10(most)
Please Select
1
2
3
4
5
6
7
8
9
10
Gum and Bone—Have you ever:
Been diagnosed or treated for periodontal (gum) disease?
Yes
No
Noticed an unpleasant taste or odor in your mouth?
Yes
No
Is there anyone with a history of periodontal disease in your family?
Yes
No
Are you aware of any sores or irritated areas in the mouth?
Yes
No
Do your gums bleed sometimes, or are they ever painful when brushing or flossing?
Yes
No
Tooth Structure—How often do you:
Do you brush?
Once a day
2x a day
3x a day
Every time I eat
Do you floss?
Once a day
2x a day
3x a day
Every time I eat
Do you have dry mouth?
Yes
No
Are any teeth sensitive to hot, cold, biting, or sweets?
Yes
No
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
Yes
No
Have you had any cavities within the past 3 years?
Yes
No
Bite and Jaw Joint— Do you experience any of the following?
Problems with your jaw joint? (Pain, limited opening, locking, popping)
Yes
No
Avoid or have difficulty chewing gum or hard, dry foods?
Yes
No
Clench or grind your teeth?
Yes
No
Ever had orthodontics?
Yes
No
If so, do you have retainers?
Yes
No
Do you wear or have you ever worn a night guard?
Yes
No
Smile Characteristics—Have you?
Have you whitened your teeth?
Yes
No
Felt uncomfortable or self-conscious about the appearance of your teeth?
Yes
No
Do you like your smile?
Yes
No
Is there anything about your teeth you'd like to change?
Shape/color
Straighten teeth
Close spaces
Restore broken teeth
Patient/Guardian Signature:
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: