DENTAL HISTORY
Patient Name
Nickname
Age
Referred by
How would you rate the condition of your mouth?
Excellent
Good
Fair
Poor
Previous Dentist
How long have you been a patient?
Months/Years
Date of 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 month
4 month
6 month
12 month
Not routinely
WHAT IS YOUR IMMEDIATE CONCERN?
PLEASE ANSWER YES OR NO OF THE FOLLOWING:
PERSONAL HISTORY
1. Are you fearful of dental treatment?
Yes
No
How fearful, on a scale of 1(lest) or 10 (most)
Least
1
2
3
4
5
6
7
8
9
Most
10
1 is Least, 10 is Most
2. Have you had an unfavorable dental experience?
Yes
No
3. Have you ever had complications from past dental treatment?
Yes
No
4. Have you ever had trouble getting numb or had any reactions to local anesthetic?
Yes
No
5. Did you ever have braces, orthodontic treatment or had you bite adjusted?
Yes
No
At what age?
6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?
Yes
No
GUM AND BONE
7. Do you gums bleed sometimes or are they ever uncomfortable when brushing or flossing?
Yes
No
8. Have you ever had or been told you have gum loss, gum disease, or bone loss between your teeth?
Yes
No
9. Have you ever noticed an unpleasant taste, odor in your mouth, or swollen and puffy gums?
Yes
No
10. Is there anyone with a history of periodontal disease in your family?
Yes
No
11. Have you ever experienced gum recession, or can you see more of the roots of your teeth?
Yes
No
12. Have you ever had any teeth become loose on their own(without an injury), or feel them move when chewing?
Yes
No
13. Have you experienced a burning, painful sensation, or metallic taste in your mouth?
Yes
No
TOOTH STRUCTURE
14. Have you had any cavities within the past 3 years?
Yes
No
15. Does the amount of saliva in your mouth seem too little, not enough, or do you have difficulty swallowing or chewing any food?
Yes
No
16. Do you feel or notice any holes, (i.e. pitting, craters) on the biting surface of your teeth?
Yes
No
17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid, brushing any part of teeth?
Yes
No
18. Do you have grooves or notches on your teeth near the gum line?
Yes
No
19. Have you ever broken teeth, chipped teeth, or had a toothache, or cracked filling?
Yes
No
20. Do you frequently get food caught between any teeth?
Yes
No
BITE AND JAW JOINT
21. Does your jaw joint ever have pain, sounds(popping, cracking), or experience limited opening or locking?
Yes
No
22. Do you feel your lower jaw his been pushed back when you try to bite your back teeth together?
Yes
No
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
Yes
No
24. In the past 5 years, have your teeth changed(become thinner, shorter, or worm) or has your bite changed?
Yes
No
25. Are your teeth becoming more crooked, crowded, or overlapped?
Yes
No
26. Are your teeth developing spaces and becoming more loose?
Yes
No
27. Do you have more than one bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
Yes
No
28. Do you place your tongue between your teeth or close your teeth against your tongue?
Yes
No
29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
Yes
No
30. Do you clench or grind your teeth together in the daytime or make them sore?
Yes
No
31. 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
32. Do you wear or have you ever worn a bite appliance?
Yes
No
SMILE CHARACTERISTICS
33. 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
34. Have you ever bleached(whitened) your teeth?
Yes
No
35. Have you felt uncomfortable or self conscious about the appearance of your teeth?
Yes
No
36. Have you been disappointed with the appearance of previous dental work?
Yes
No
Patient's Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: