DENTAL HISTORY FORM
Name
*
First Name
Last Name
Nickname
Referred by
How would you rate the condition of your mouth?
Excellent
Good
Fair
Poor
Previous dentist
How long have you been a patient?
Date of most recent dental exam?
Date of most recent xrays?
Date of most recent treatment (other than a cleaning)
I routinely see my dentist every
3 months
4 months
6 months
12 months
Not routinely
Do you have any immediate concerns?
Personal History
How fearful of dental treatment are you?
*
1
2
3
4
5
6
7
8
9
10
Least
Most
1 is Least, 10 is Most
2. Have you had an unfavourable 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 your bite adjusted?
YES
NO
6. Have you had any teeth removed?
YES
NO
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GUM AND BONE
Please answer yes or no to the following:
7. Do your gums bleed or are they painful when brushing or flossing?
YES
NO
8. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
YES
NO
9. Have you ever noticed an unpleasant taste or odor in your mouth?
YES
NO
10. Is there a family history of periodontal disease?
YES
NO
11. Have you ever experienced gum recession?
YES
NO
12. Have your teeth ever become loose on their own, or do you have difficulty eating an apple?
YES
NO
13. Have you ever experienced a burning sensation in your mouth?
YES
NO
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TOOTH STRUCTURE
Please answer yes or no to the following:
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 or do you have difficulty swallowing food?
YES
NO
16. Do you feel or notice any holes (pitting/craters) on the biting surface of your teeth?
YES
NO
17. Are any teeth sensitive to hot, cold, biting, sweets or avoid brushing any part of your 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 fillings?
YES
NO
20. Do you frequently get food caught between your teeth?
YES
NO
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BITE AND JAW JOINT
Please answer yes or no to the following:
21. Do you have problems with your jaw joint? ie) pain, sounds, limited opening, locking, popping
YES
NO
22. Do you feel like your lower jaw is being pushed back when you bite your teeth together?
YES
NO
23. Do you avoid or have difficulty chewing gum, carrots, nuts, baguettes, protein bars, or other hard/dry foods?
YES
NO
24. Have your teeth changed in the last 5 years, become thinner, shorter, or worn?
YES
NO
25. Are your teeth becoming more crooked, crowded or overlapped?
YES
NO
26. Are your teeth developing spaces or becoming more loose?
YES
NO
27. Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together?
YES
NO
28. Do you place your tongue between your teeth or rest 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 your teeth in the daytime or make them sore?
YES
NO
31. Do you have any problems with sleep (ie. restlessness), 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
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SMILE CHARACTERISTICS
Please answer yes or no to the following:
33. Is there anything about the appearance of your teeth that you would like to change?
YES
NO
34. Have you ever 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
Signature
*
Submit
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