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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