Your Name (required)

    Nickname

    Your Email (required)

    Age

    Referred by

    How would you rate the condition of your mouth?
    ExcellentGoodFairPoor

    Previous Dentist

    How long have you been a patient?

    Date of most recent dental exam

    Date of most recent x-rays

    Date of most recent treatment (other than a cleaning)

    I routinely see my dentist every:
    3 mo.4 mo.6 mo.12 mo.Not routinely

    WHAT IS YOUR IMMEDIATE CONCERN?

    PLEASE ANSWER YES OR NO TO THE FOLLOWING:

    PERSONAL HISTORY

    1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)
      012345678910
    2. Have you had an unfavorable dental experience?
      YesNo
    3. Have you ever had complications from past dental treatment?
      YesNo
    4. Have you ever had trouble getting numb or had any reactions to local anesthetic?
      YesNo
    5. Did you ever have braces, orthodontic treatment or had your bite adjusted?
      YesNo
    6. Have you had any teeth removed?
      YesNo

      7. SMILE CHARACTERISTICS

    7. Is there anything about the appearance of your teeth that you would like to change?
      YesNo
    8. Have you ever whitened (bleached) your teeth?
      YesNo
    9. Have you felt uncomfortable or self conscious about the appearance of your teeth?
      YesNo
    10. Have you been disappointed with the appearance of previous dental work?
      YesNo

      11. BITE AND JAW JOINT

    11. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
      YesNo
    12. Do you / would you have any problems chewing gum?
      YesNo
    13. Do you / would you have any problems chewing bagels, baguettes , protein bars, or other hard foods?
      YesNo
    14. Have your teeth changed in the last 5 years, become shorter, thinner or worn?
      YesNo
    15. Are your teeth crowding or developing spaces?
      YesNo
    16. Do you have more than one bite and squeeze to make your teeth fit together?
      YesNo
    17. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
      YesNo
    18. Do you clench your teeth in the daytime or make them sore?
      YesNo
    19. Do you have any problems with sleep or wake up with an awareness of your teeth?
      YesNo
    20. Do you wear or have you ever worn a bite appliance?
      YesNo

      21. TOOTH STRUCTURE

    21. Have you had any cavities within the past 3 years?
      YesNo
    22. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
      YesNo
    23. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
      YesNo
    24. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?
      YesNo
    25. Do you have grooves or notches on your teeth near the gum line?
      YesNo
    26. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
      YesNo
    27. Do you frequently get food caught between any teeth?
      YesNo

      28. GUM AND BONE

    28. Do your gums bleed or are they painful when brushing or flossing?
      YesNo
    29. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
      YesNo
    30. Have you ever noticed an unpleasant taste or odor in your mouth?
      YesNo
    31. Is there anyone with a history of periodontal disease in your family?
      YesNo
    32. Have you ever experienced gum recession?
      YesNo
    33. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
      YesNo
    34. Have you experienced a burning sensation in your mouth?
      YesNo

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