Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Reason for this visit
*
What was done at your last dental visit?
*
How often did you visit the dentist before then?
*
Previous Dentist?
Have you had a complete series of dental films (X-Rays) taken?
*
Yes
No
If so, when and where?
How often do you brush your teeth?
*
How often do you floss your teeth?
*
Back
Next
Is your drinking water fluoridated?
*
Yes
No
Not Sure
Do your gums bleed while brushing or flossing?
*
Yes
No
Are your teeth sensitive to hot or cold liquids/foods?
*
Yes
No
Do any of your teeth feel painful?
*
Yes
No
Do you have any sores or lumps in or near your mouth?
*
Yes
No
Have you had any head, neck, or jaw injuries?
*
Yes
No
Have you experienced any of the following problems:
Clicking in your jaw
Pain (joint, ear, side of face)
Difficulty in opening or closing your jaw
Difficulty in chewing
Do you have frequent headaches?
*
Yes
No
Do you clench or grind your teeth?
*
Yes
No
Do you bite your lips or cheeks frequently?
*
Yes
No
Have you noticed any loosening of your teeth?
*
Yes
No
Does food tend to become caught between your teeth?
*
Yes
No
Have you ever had periodontal treatment (gums)?
*
Yes
No
Have you ever worn a bite plate or other appliance?
*
Yes
No
Have you had any difficult extractions in the past?
*
Yes
No
Have you ever had any prolonged bleeding following extractions?
Yes
No
Do you wear dentures or partials?
*
Yes
No
If yes, give the date they were placed:
-
Month
-
Day
Year
Date
Have you ever received oral hygiene instructions regarding the care of your teeth and gums?
*
Yes
No
If you could change anything about your smile, what would you change?
*
AUTHORIZATION AND RELEASE
I certify that I have read and understood the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
Submit
Reason For Visit
Date of Birth
-
Month
-
Day
Year
Date
Should be Empty: