Dental Information
Patient Name:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
The following information is for our records and will be kept confidential.
Are you having any dental pain now?
Yes
No
When was your last dental visit?
-
Month
-
Day
Year
Date
What was done at that time?
Do you floss?
Yes
No
How often?
How many time a day do you brush?
What type of toothbrush are you currently using?
Manual
Mechanical
Are you sensitive to hot or cold?
Yes
No
Are you sensitive to sweets?
Yes
No
Are you sensitive to biting or chewing?
Yes
No
Have you noticed any bad breath or bad tastes?
Yes
No
What type of toothpaste and/or rinse do you use?
Do you frequently get cold sores or any other oral lesions?
Yes
No
Do your gums ever bleed or hurt?
Yes
No
Have your parents lost any teeth or had gum disease?
Yes
No
Do you have any family history or Diabetes?
Yes
No
Do you smoke or chew tobacco?
Yes
No
Have you noticed any loose teeth or a change in your bite?
Yes
No
Does food tend to get caught between your teeth?
Yes
No
Do you clench or grind your teeth while awake or asleep?
Yes
No
Do you breathe by your mouth while awake or asleep?
Yes
No
Do you have tired jaws, especially in the morning?
Yes
No
Have you had orthodontic treatment (braces)?
Yes
No
Have you had oral surgery (extractions)?
Yes
No
Have you had periodontal treatment (gum disease)?
Yes
No
Have you had your teeth ground or bite adjusted?
Yes
No
Do you have a bite plate or mouth guard?
Yes
No
Have you had any serious injury to your mouth or head?
Yes
No
Do you have clicking or popping in your jaws?
Yes
No
Do you have headaches, neck or shoulder pain?
Yes
No
What do you think about losing your teeth?
Is there anything about your smile or bite that you wish to change?
What are your concerns (if any) about having dental treatment?
Submit
Should be Empty: