Dental History Form

* Denotes Required

Name* :
Email*:
Nickname:
Age:
Referred By:
How would you rate the condition of your mouth? ExcellentGoodFairPoor
Previous dentist:
How long have you been a patient: Months/Years
Date of most recent dental exam:
Date of the most recent x-rays:
Date of the most recent treatment (other than cleaning):
I routinely see my dentist every: 3 months4 months6 months12 monthsNot routinely
WHAT IS YOUR IMMEDIATE CONCERN?

PLEASE ANSWER YES OR NO TO THE FOLLOWING:

PERSONAL HISTORY

1. Are you fearful of dental treatment? YESNO
    How fearful, on a scale of 1 (least) to 10 (most)
2. Have you had an unfavorable dental experience? YESNO
3. Have you ever had complications from past dental treatment? YESNO
4. Have you ever had trouble getting numb or had any reactions to local anesthetic? YESNO
5. Did you ever have braces, orthodontic treatment or had your bite adjusted? YESNO
6. Have you had any teeth removed? YESNO

GUM AND BONE

7. Do your gums bleed or are they painful when brushing or flossing? YESNO
8. Have you ever been treated for gum disease or been told you have lost bone around your teeth? YESNO
9. Have you ever noticed an unpleasant taste or odor in your mouth? YESNO
10. Is there anyone with a history of periodontal disease in your family? YESNO
11. Have you ever experienced gum recession? YESNO
12. Have you ever had any teeth become loose on their own (without an injury),
       or do you have difficulty eating an apple?
YESNO
13. Have you experienced a burning sensation in your mouth? YESNO

TOOTH STRUCTURE

14. Have you had any cavities within the past 3 years? YESNO
15. Does the amount of saliva in your mouth seem too little or do you have difficulty in swallowing any food? YESNO
16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? YESNO
17. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth? YESNO
18. Do you have grooves or notches on your teeth near the gum line? YESNO
19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? YESNO
20. Do you frequently get food caught between any teeth? YESNO

BITE AND JAW JOINT

21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) YESNO
22. Do you feel like your lower jaw is being pushed back when you bite your teeth together? YESNO
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars,
       or other hard, dry foods?
YESNO
24. Have your teeth changed in the last 5 years, become shorter, thinner or worn? YESNO
25. Are your teeth crowding or developing spaces? YESNO
26. Do you have more than one bite and squeeze to make your teeth fit together? YESNO
27. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? YESNO
28. Do you clench your teeth in the daytime or make them sore? YESNO
29. Do you have any problems with sleep or wake up with an awareness of your teeth? YESNO
30. Do you wear or have you ever worn a bite appliance? YESNO

SMILE CHARACTERISTICS

31. Is there anything about the appearance of your teeth that you would like to change? YESNO
32. Have you ever whitened (bleached) your teeth? YESNO
33. Have you felt uncomfortable or self-conscious about the appearance of your teeth? YESNO
34. Have you been disappointed with the appearance of previous dental work? YESNO

Patient's acceptance: Accepted

Today's date:

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