www.titusdentistrymiddletown.com - Dental History Form

Dental History - Middletown
Patient Name*

First NameMiddle NameLast Name
Dental History
Why do we ask?

At Titus Dentistry, we have a set of values that are important to us and how we treat our patients. But we don’t assume to know what YOU think is important. We know that no two people are the same. We also know that no two mouths are the same. This is where we find out how to best serve your wants and needs. We know that this is one more piece of paper to fill out... but we think it is the most important!
Previous Dentist's Name
Date of Last Dental Exam

MonthDayYear
Date
How often do you brush?
How often do you floss?
What other dental aides do you use? (toothpick, Water Pik, fluoride, etc.)
Please describe any current dental problems
What is your biggest dental concern?
I have had

Orthodontics (Braces)Oral SurgeryPeriodontal Treatment
My teeth are sensitive to

HeatColdSweetsBiting/Chewing
Please Check all that apply

My gums bleed/hurtI have a family history of gum diseaseFood tends to get caught in my teeth.I know that I mouth breath while awake or asleep.I notice my jaws get tired sometimes.I have been diagnosed with a problem with either jaw joint.I have pain or tenderness in my jaw joint when I open, close, or chew.I have frequent headaches.I have noticed loose teeth or changes in my bite.I have bad breathI bite my lips or cheeks regularly.I snore.I have been diagnosed with a breathing or sleeping disorder.My jaw has locked open or closed before.My jaw joints click, pop, or make noise when I open and close.I clench or grind my teeth.
Are you anxious about having your dental treatment completed?*

YesNo
What can we do to help you with your anxiety while at our office?*
Are you satisfied with the appearance of your teeth?

YesNo
What would you like to change?*
Is there anything else about having dental treatment that you would like us to know?
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Please verify that you are human*
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Dental History - Middletown

Dental History