Dr. Robert Oliveros

604-275-3361

richmond dentist
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      • Digital X-rays
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      • Dental x-rays
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      • Composite Fillings
      • Crowns (Caps)
      • Bridges
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      • Root Canal Treatment
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      • Extractions
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      • Porcelain Crowns
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      • Porcelain Bridges
      • Porcelain Inlays/Onlays
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Dental History Form

Home » Dental History Form

How would you rate the condition of your mouth?
I routinely see my dentist every:
Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)
Have you had an unfavorable dental experience?
Have you ever had complications from past dental treatment?
Have you ever had trouble getting numb or had any reactions to local anesthetic?
Did you ever have braces, orthodontic treatment or had your bite adjusted?
Have you had any teeth removed?
Is there anything about the appearance of your teeth that you would like to change?
Have you ever whitened (bleached) your teeth?
Have you felt uncomfortable or self conscious about the appearance of your teeth?
Have you been disappointed with the appearance of previous dental work?
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
Do you / would you have any problems chewing gum?
Do you / would you have any problems chewing bagels, baguettes , protein bars, or other hard foods?
Have your teeth changed in the last 5 years, become shorter, thinner or worn?
Are your teeth crowding or developing spaces?
Do you have more than one bite and squeeze to make your teeth fit together?
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
Do you clench your teeth in the daytime or make them sore?
Do you have any problems with sleep or wake up with an awareness of your teeth?
Do you wear or have you ever worn a bite appliance?
Have you had any cavities within the past 3 years?
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?
Do you have grooves or notches on your teeth near the gum line?
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
Do you frequently get food caught between any teeth?
Do your gums bleed or are they painful when brushing or flossing?
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
Have you ever noticed an unpleasant taste or odor in your mouth?
Is there anyone with a history of periodontal disease in your family?
Have you ever experienced gum recession?
Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
Have you experienced a burning sensation in your mouth?


Hours of Operation

Monday 9:00AM - 6:00PM
Tuesday 9:00AM - 5:00PM
Wednesday 9:00AM - 5:00PM
Thursday 8:00AM - 6:00PM
Friday Closed
Saturday 8:00AM - 5:00PM *
Sunday Closed

* We are open one Saturday a month.

Late appointments available upon request.

  • Home
  • Meet Dr. Oliveros
  • Before & After
  • Financial Info
  • FAQ’s
  • Promotions
  • Contact Us

  • Preventive Dentistry
  • General Dentistry
  • Cosmetic Dentistry
  • Periodontal Disease
  • Implants
  • Orthodontics

Dr. Robert Oliveros Inc.

Suite 220 - 6180 Blundell Road
Richmond, BC V7C 4W7

Phone: 604-275-3361
Fax: 604-275-3085
email: info@drrobertoliveros.com


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Copyright © Dr. Robert Oliveros – Richmond Dentist Dental website design by SmartWeb Canada.

  • Home
  • Meet the Team
    • Meet Dr. Oliveros
    • Meet the staff
    • Back
  • Services
    • Preventive Dentistry
      • Digital X-rays
      • Dental Exams and Cleanings
      • Dental x-rays
      • Fluoride
      • Sealants
      • Back
    • General Dentistry
      • Composite Fillings
      • Crowns (Caps)
      • Bridges
      • Inlays/Onlays
      • Root Canal Treatment
      • Complete & Partial Dentures
      • Extractions
      • Mouthguards
      • Back
    • Cosmetic Dentistry
      • Porcelain Crowns
      • Porcelain Veneers
      • Porcelain Bridges
      • Porcelain Inlays/Onlays
      • Teeth Whitening
      • Back
    • Periodontal Disease
      • Diagnosis
      • Treatment
      • Periowave™
      • Maintenance
      • Back
    • Orthodontics
      • Invisalign
      • Back
    • Back
  • Gallery
    • Before & After
    • Back
  • Financial Info
  • FAQ’s
  • Promotions
  • Contact Us
    • New Patient Forms
      • Medical History Form
      • Dental History Form
      • Back
    • Back
  • Blog
Welcome Back

We are excited to tell you that we are open once again and welcome you back! We have always prided ourselves in providing a safe and clean environment, but in light of the COVID-19 Pandemic we have instituted additional guidelines and protocols to ensure your safety.

Learn More