Dental History
Patient First Name
First Name
Last Name
Reason for today's office visit?
Previous Dentist
Why are you changing your dentist?
When was your last dental exam
When did you have your last dental cleaning
Personal History
How often do you brush?
Every time I eat,
Three times a day,
Twice a day,
Once a day,
Occasionally,
Sometimes,
Never,
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How often do you floss?
Every time I eat,
Twice a day,
Occasionally,
Never,
Three times a day,
Once a day,
Sometimes,
Does going to the dentist make you nervous?
No,
Yes, moderately,
Yes, slightly,
Yes, extremely,
Have you ever had a bad experience at the dentist?
Yes
No
Please add any details here
Have you ever had complications from past dental treatment?
Yes
No
Please add any details here
Have you ever had trouble getting numb or had any reactions to local anesthetic?
Yes
No
Please add any details here
Have you ever had orthodontic (braces) treatment?
Yes
No
Do you wear dentures or partials?
Yes
No
If yes, approximately how old and are you satisfied with it?
Do you wear dentures or partials?
Yes
No
Periodontal / Gum disease
Do your gums bleed sometimes or are they ever painful when brushing or flossing?
Yes
No
Please add any details here
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
Yes
No
Please add any details here
Is there anyone with a history of gum / periodontal disease in your family?
Yes
No
Please add any details here
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Have you ever experienced or been told by a previous dentist that you have gum recession, or can you see more of the roots of your teeth? yes / no
Yes
No
Please add any details here
Have you ever had any teeth become loose without an external injury, or do you have difficulty biting into harder fruits and vegetables? yes / no
Yes
No
Please add any details here
Dental Problems
Are your teeth sensitive to hot, cold, sweet foods or liquids? Do you avoid brushing a part of your mouth because of sensitive teeth?
Yes
No
Please add any details here
Do you feel that your mouth is too dry or had difficulty swallowing food?
Yes
No
Please add any details here
Do you frequently get food caught between any teeth?
Yes
No
Please add any details here
Are you aware of sores or irritated areas in the mouth?
Yes
No
Please add any details here
Do you grind your teeth? Have you been told by a partner or a previous dentist that you grind your teeth?
Yes
No
If yes, do you wear a nightguard
Do you have any earaches or neck pains?
Yes
No
Do you have any clicking, popping, or discomfort in the jaw?
Yes
No
Improvements
How would you rate your smile (1-5)?
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Is there something you would like to change about your smile?
The color of my teeth,
Close spaces or restore worn out / broken teeth,
Change the shape of my teeth,
Make my teeth straighter,
Replace missing teeth,
Nothing, I like my smile,
Other,
I would be interested in learning more about the following topics
Teeth whitening,
Cosmetic evaluation,
Replacement of missing teeth,
Straight teeth,
Sedation,
White fillings,
Home care,
Breath control,
None of the above,
Other,
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