Dental History
Name
*
First Name
Last Name
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Next
1. Are you having any discomfort at this time?
*
Yes
No
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2. How long since your last dental visit?
*
3. Did you have x-rays taken?
*
4. What was done at your last visit?
*
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Next
5. Have you lost any teeth?
*
6. Any complications with extractions?
*
7. Have the missing teeth been replaced by:
*
Fixed Bridge
Implants
No
Other
8. Are your teeth sensitive to any of the following:
*
Heat
Cold
Sweets
Sour
No
Other
Where?
9. Have you had your teeth straightened?
*
Yes
No
10. Are you happy with your smile?
*
Yes
No
11. Do you wish your teeth were whiter?
*
Yes
No
12. Do you floss?
*
Yes
No
How often?
13. How long have you been flossing?
14. Do you use a sonic brush?
*
Yes
No
15. Other home care aids?
16. Do you have bleeding gums?
*
Yes
No
Where?
17. Do you drink carbonated beverages?
*
Yes
No
What kind?
How many per day?
18. Does food wedge between your teeth?
*
Yes
No
Where?
19. Have you ever had gum treatments?
*
Yes
No
What was done and when?
20. Do you grind or clench your teeth?
*
Yes
No
When?
21. Do you have a nightguard?
*
Yes
No
If yes,
Upper
Lower
22. Do you hear clicking?
*
Yes
No
Popping?
*
Yes
No
23. Noises when you chew?
*
Yes
No
If yes, Right, Left or Both?
24. Has you jaw ever locked open/closed?
*
Yes
No
When?
25. Any pain in or around your ears?
*
Yes
No
26. Do you have headaches more than once weekly?
*
Yes
No
27. Do you now or have you ever had the habit of any of the following:
*
Thumbsucking
Fingersucking
Cheek/tongue chewing
Chewing on pencils
Chewing on pens
Chewing on lips
Chewing on fingernails
None
28. Do you have any fear of having dentistry done?
*
Yes
No
Explain:
29. How do you feel about your teeth?
Submit
Should be Empty: