DENTAL HISTORY
11150 Sunset Hills Road, Ste 303 Reston, VA 20190
Patient Name:
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DOB:
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Month
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Day
Year
Date of Last Dental Visit:
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Month
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Day
Year
Did your dentist advise any treatment that you have not yet done?
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Yes
No
Has the fear or discomfort kept you from regular dental visits?
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Yes
No
What is the goal you have for your Smile:
What is the goal you have for your Teeth:
Have you ever had:
Orthodontic treatment
Periodontal treatment
TMD treatment
Root Canal treatment
Bite adjustment
Serious injury to mouth or head
Check any that apply:
Do your gums bleed or hurt?
Have your parents experienced gum disease or tooth lose?
Have you noticed any loose teeth or change in your bite?
Does food tend to get caught in between your teeth?
Do you smoke / chew tobacco?
Do you mouth breath while awake or sleep?
Have you noticed any mouth odors or bad taste?
Have you experienced:
Clicking or popping of the jaw?
Jaw Pain? (joint, ear, side of face)
Pain in head, neck, shoulders, or back?
Difficulty in opening or closing your mouth?
Tired jaws, especially in the morning?
Clenching or grinding your teeth while awake or sleep?
Do you chew gum often?
Sensitive teeth to cold, hot, sweets, biting, or chewing?
Frequent cold sores, blisters, or any other lesion?
What don't you like about your teeth?
Unsightly restorations
Missing teeth
Tooth shape
Tooth color
Bite
Smile
How often do you Brush:
How often do you Floss:
Do you use any other dental aids?:
Patient Signature:
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Submit
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