Dental History
Name:
*
First Name
Last Name
Nickname:
Age:
*
Referred by:
*
First Name
Last Name
How would you rate the condition of your mouth?
*
Excellent
Good
Fair
Poor
Previous dentist:
First Name
Last Name
How long have you been a patient (months/years)?
Date of most recent dental exam:
*
-
Month
-
Day
Year
Date of most recent x-rays:
-
Month
-
Day
Year
Date of most recent treatment (other than a cleaning)?
-
Month
-
Day
Year
Date
I routinely see my dentist every:
*
3 months
4 months
6 months
12 months
Not routinely
What is your most immediate concern?
PLEASE ANSWER YES OR NO TO THE FOLLOWING:
Personal History
Are you fearful of dental treatment?
*
Yes
no
How fearful, on a scale of 1 (least) to 10 (most)
*
Have you had an unfavorable dental experience?
*
Yes
no
Have you ever had complications from past dental treatment?
*
Yes
no
Have you ever had trouble getting numb or had any reactions to local anesthetic?
*
Yes
no
Did you ever have braces, orthodontic treatment or had your bite adjusted?
*
Yes
no
If yes, at what age?
Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?
*
Yes
no
Gum and Bone
Do your gums bleed or are they painful when brushing or flossing?
*
Yes
no
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
*
Yes
no
Have you ever noticed an unpleasant taste or odor in your mouth?
*
Yes
no
Is there anyone with a history of periodontal disease in your family?
*
Yes
no
Have you ever experienced gum recession?
*
Yes
no
Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
*
Yes
no
Tooth Structure
Have you had any cavities within the past 3 years?
*
Yes
no
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
*
Yes
no
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
*
Yes
no
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
*
Yes
no
Do you have grooves or notches on your teeth near the gum line?
*
Yes
no
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
*
Yes
no
Do you frequently get food caught between any teeth?
*
Yes
no
Bite and Jaw Joint
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
*
Yes
no
Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?
*
Yes
no
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
*
Yes
no
In the past 5 years, have your teeth changed (become shorter, thinner, or worn ) or has your bite changed?
*
Yes
no
Are your teeth becoming more crooked, crowded, or overlapped?
*
Yes
no
Are your teeth developing spaces or becoming more loose?
*
Yes
no
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?
*
Yes
no
Do you place your tongue between your teeth or close your teeth against your tongue?
*
Yes
no
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
*
Yes
no
Do you clench or grind your teeth together in the daytime or make them sore?
*
Yes
no
Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
*
Yes
no
Do you wear or have you ever worn a bite appliance?
*
Yes
no
Smile Characteristics
Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?
*
Yes
no
Have you ever whitened (bleached) your teeth?
*
Yes
no
Have you felt uncomfortable or self conscious about the appearance of your teeth?
*
Yes
no
Have you been disappointed with the appearance of previous dental work?
*
Yes
no
Signature:
*
Use your mouse to sign by holding down the button continuously with your index finger and signing/moving the mouse in the signature box. When finished, select date and press "Submit"
Clear
Date:
*
-
Month
-
Day
Year
Submit
Should be Empty: