Ross - miamiperiodontist - Dental History

Full Name

Date

Reason for visit

General Dentist Name

How Long?

Do you have pain in any area of your mouth today?

Last Dental Cleaning?

Last X-Ray?

Indicate which of the following you have had, or have at present:

Does food tend to become caught in your teeth?

YesNo

If yes, where?

Periodontal (Gum) treatment?

YesNo

Do you get frequent headaches?

YesNo

Orthodontic treatment (braces)?

YesNo

Do you have pain around the ears?

YesNo

Your teeth ground or bite adjusted?

YesNo

Do your jaws ever hurt or feel tired?

YesNo

A bite plate or mouth guard?

YesNo

Do you have any mouth habits?

YesNo

Do your gums bleed or hurt?

YesNo

Do you mouth breath while awake or asleep?

YesNo

Have your parents experienced gum disease/tooth loss?

YesNo

Are you satisfied with your teeth's appearance?

YesNo

Have you noticed any loose teeth or change in your bite?

YesNo

Would you like to keep all of your teeth all of your life?

YesNo

Are any of your teeth sensitive to hot, cold or sweets?

YesNo

Have you noticed any mouth odors or bad taste?

YesNo

Is there anything else about having dental treatment that you would like us to know?

YesNo

If yes, what?

Do you feel nervous about having dental treatment?

YesNo

If so, what is your biggest concern?

A serious injury to the mouth or head?

YesNo

If so, please describe including cause

Have you ever had an upsetting dental experience?

YesNo

If so, please describe.

Do you frequently get cold sores, blisters or any other oral lesions?

YesNo

Do you clench or grind your teeth while awake/asleep?

YesNo

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge.

CONSENT

The undersigned hereby authorizes Doctor to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize Doctor to perform any and all forms of treatment, medication and therapy, that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for Dental Services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I further understand that a finance charge will be added to any overdue balance.

Patient's Signature (Parent or Guardian of Child)

Clear

Date