DENTAL HISTORY
Patient Name
*
First Name
Last Name
Nickname
Age
Referred by
How would you rate the condition of your mouth?
Excellent
Good
Poor
Fair
Describe
Previous Dentist
Date of the most recent dental exam
-
Month
-
Day
Year
Date
Date of most recent X-rays
-
Month
-
Day
Year
Date
Date of most recent treatment (other than a cleaning)
-
Month
-
Day
Year
Date
I routinely see my dentist every
3 mo.
4 mo.
6 mo.
12 mo.
Not routinely
WHAT IS YOUR IMMEDIATE CONCERN?
Please answer "Yes" or "No" to the following
PERSONAL HISTORY
Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)
*
Least
1
2
3
4
5
6
7
8
9
Most
10
1 is Least, 10 is Most
Have you had an unfavorable dental experience?
*
Yes
No
If "Yes" Please Explain
*
Have you ever had complications from past dental treatment?
*
Yes
No
If "Yes" Please Explain
*
Have you ever had trouble getting numb or had any reactions to local anesthetic?
*
Yes
No
If "Yes" Please Explain
*
Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
*
Yes
No
If "Yes" Please Explain
*
Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?
*
Yes
No
If "Yes" Please Explain
*
GUM AND BONE
Do your gums bleed sometimes or are they ever painful when brushing or flossing?
*
Yes
No
If "Yes" Please Explain
*
Have you ever been treated for gum disease, had scaling and root planing, or been told you have lost bone around your teeth?
*
Yes
No
If "Yes" Please Explain
*
Have you ever noticed an unpleasant taste or odor in your mouth?
*
Yes
No
If "Yes" Please Explain
*
Is there anyone with a history of periodontal disease in your family?
*
Yes
No
If "Yes" Please Explain
*
Have you ever experienced gum recession, or can you see more of the roots of your teeth?
*
Yes
No
If "Yes" Please Explain
*
Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
*
Yes
No
If "Yes" Please Explain
*
Have you experienced a burning or painful sensation in your mouth not related to your teeth?
*
Yes
No
If "Yes" Please Explain
*
TOOTH STRUCTURE
Have you had any cavities within the past 3 years?
*
Yes
No
If "Yes" Please Explain
*
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
*
Yes
No
If "Yes" Please Explain
*
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
Yes
No
If "Yes" Please Explain
*
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
*
Yes
No
If "Yes" Please Explain
*
Do you have grooves or notches on your teeth near the gum line?
*
Yes
No
If "Yes" Please Explain
*
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
*
Yes
No
If "Yes" Please Explain
*
Do you frequently get food caught between any teeth?
*
Yes
No
If "Yes" Please Explain
*
BITE AND JAW JOINT
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
*
Yes
No
If "Yes" Please Explain
*
Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?
*
Yes
No
If "Yes" Please Explain
*
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
*
Yes
No
If "Yes" Please Explain
*
In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?
*
Yes
No
If "Yes" Please Explain
*
Are your teeth becoming more crooked, crowded, or overlapped?
*
Yes
No
If "Yes" Please Explain
*
Are your teeth developing spaces or becoming more loose?
*
Yes
No
If "Yes" Please Explain
*
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
If "Yes" Please Explain
*
Do you place your tongue between your teeth or close your teeth against your tongue?
*
Yes
No
If "Yes" Please Explain
*
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
*
Yes
No
If "Yes" Please Explain
*
Do you clench or grind your teeth together in the daytime or make them sore?
*
Yes
No
If "Yes" Please Explain
*
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
If "Yes" Please Explain
*
Do you wear or have you ever worn a bite appliance?
*
Yes
No
If "Yes" Please Explain
*
SMILE CHARACTERISTICS
Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size, display)?
*
Yes
No
If "Yes" Please Explain
*
Have you ever bleached (whitened) your teeth?
*
Yes
No
If "Yes" Please Explain
*
Have you felt uncomfortable or self conscious about the appearance of your teeth?
*
Yes
No
If "Yes" Please Explain
*
Have you been disappointed with the appearance of previous dental work?
*
Yes
No
If "Yes" Please Explain
*
Patient Signature
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
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