• Dental History

  • Choose Title*

  • Your answers to this dental history questionnaire will help us to understand your specific dental issues, so that we may more effectively treat you with consideration for your individual needs.

  • Approximate Date of Last Visit*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Approximate Date of Last Visit
     - -
    2 digit month, 2 digit day, 4 digit year
  • Last dental cleaning*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you ever had orthodontics?*
  • Are you presently in pain?*

  • Is any part of your mouth sensitive to the following:*

  • Do you have a burning sensation in your mouth?*
  • Are you troubled with dryness in your mouth?*
  • Do you have any pain or soreness around your eyes, ears, or other parts of your face?*
  • Do you have chronic headaches?*
  • Do you have chronic neck-aches?*
  • Do you have chronic back pain?*
  • Have you ever been informed that you have gum problems?*
  • Do your gums ever bleed when you brush your teeth?*
  • Do you have any food packing spots in your mouth*
  • Are you able to chew on both sides of your mouth without pain?*
  • Are you aware of a bad taste or odor in your mouth?*
  • Please indicate which items you use daily:*

  • Are you aware of any growths or swellings in your mouth?*
  • Are you aware of your jaw clicking, popping or making grating-like noise?*
  • Are you aware of clenching your teeth during the day?*
  • Have you ever been told you grind your teeth during sleep?*
  • Are you dissatisfied with the appearance of your teeth?*
  • Do you wear a removable denture or appliance?*
  • Are you frustrated by needing constant dental repair because of your active dental disease?*

  • This is a fill in the field. Please add appropriate * fields and text.

  • Should be Empty: