Dental History
Name
*
First Name
Last Name
My mouth is
Very comfortable
Moderately comfortable
Uncomfortable
My present state of dental health is
Excellent
Good
Fair
Poor
I want my dental health to be
Excellent
Good
Fair
Poor
The appearance of my mouth is
Excellent
Good
Fair
Poor
I grew up with dental care that was
Excellent
Good
Fair
Poor
My experience with dentistry has been
Excellent
Good
Fair
Poor
What are some questions about dentistry or oral health that you have never had answered?
What are your goals for your dental health?
What are your concerns about your mouth?
Have you had any of the following treatment?
Braces
Gum treatment
Oral surgery
Root canals
Night/Bite guard
Bite adjustments
Have you experienced TMJ/Jaw problems?
Clicking/Popping
Pain
Locking
Headaches
Neck pain
Difficulty chewing/opening
Tired jaw
Do you experience:
Sensitivity/pain?
Yes
No
Hot
Cold
Biting/chewing
Cold sores or oral ulcerations
Yes
No
Gum bleeding or problems
Yes
No
Receeding gums
Yes
No
Loose teeth or change in bite
Yes
No
Catching food between your teeth?
Yes
No
Where
Clenching and/or grinding
Yes
No
Worn or chipping teeth
Yes
No
Do you feel nervous about having dental treatment?
Biggest concern:
Have you had bad or upsetting dental experiences?
Previous dentist
Address
May we get previous records
Last dental visit
What was done
Last hygiene visit
Last x-rays
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
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