Dental History

Patient Name *

First Name Middle Name Last Name

Nickname

Age *

Patient Email *

example@example.com

Referred By

How would you rate the condition of your mouth? *

Excellent Good Fair Poor

Previous Dentist

How long have you been a patient (in months/years)?

Date of your most recent dental exam *

Date

Date of most recent x-rays *

Date

Date of most recent treatment (other than a cleaning) *

Date

I routinely see my dentist every *

3 months 4 months 6 months 12 months Not routinely

What is your immediate concern? *

Personal History *

	Yes	No
Are you fearful of dental treatment?
Have you had an unfavorable dental experience?
Have you ever had complications from past dental treatment?
Have you ever had trouble getting numb or had any reactions to local anesthetic?
Did you ever have braces, orthodontic treatment, or had your bite adjusted?
Have you had any teeth removed, missing teeth that never developed, or lost teeth due to injury or facial trauma?

How fearful of dental treatment are you?

	1	2	3	4	5	6	7	8	9	10

1 is Least, 10 is Most

At what age did you have braces, orthodontic treatment, or your bite adjusted (if any)?

Gum and Bone *

	Yes	No
Do your gums bleed or are they painful when brushing or flossing?
Have you ever been treated for gums disease or been told you have lost bone around your teeth?
Have you ever noticed an unpleasant taste or odor in your mouth?
Is there anyone with a history of periodontal disease in your family?
Have you ever experienced gum recession?
Have you ever had any teeth become loose on their own (without injury), or do you have difficulty eating an apple?
Have you experienced a burning or painful sensation in your mouth not related to your teeth?

Tooth Structure *

	Yes	No
Have you had any cavities within the past 3 years?
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing food?
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
Do you have grooves or notches on your teeth near the gum line?
Have you ever broken teeth, chipped teeth, or had toothache or cracked filling?
Do you frequently get food caught between any teeth?

Bite and Jaw Joint *

	Yes	No
Do you have problems with your jaw joint? (Pain, sounds, limited opening, locking, popping)
Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
In the past 5 years, have your teeth changed (becomes shorter, thinner, or worn) or has your bite changed?
Are your teeth becoming more crooked, crowded, or overlapping?
Are your teeth developing spaces or becoming more loose?
Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
Do you place your tongue between your teeth or close your teeth against your tongue?
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
Do you clench or grind your teeth together in the daytime or make them sore?
Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
Do you wear or have you ever worn a bite appliance?

Smile Characteristics *

	Yes	No
Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?
Have you ever whitened (bleached) your teeth?
Have you felt uncomfortable or self conscious about the appearance of your teeth?
Have you been disappointed with the appearance of the previous dental work?

Patient's Signature *

Clear

Date *

Date

Please Answer Yes or No to the Following: