Dental History Form

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?

Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)012345678910

Have you had an unfavorable dental experience?YesNo

Have you ever had complications from past dental treatment?YesNo

Have you ever had trouble getting numb or had any reactions to local anesthetic?YesNo

Did you ever have braces, orthodontic treatment or had your bite adjusted?YesNo

Have you had any teeth removed?YesNo

Is there anything about the appearance of your teeth that you would like to change?YesNo

Have you ever whitened (bleached) your teeth?YesNo

Have you felt uncomfortable or self conscious about the appearance of your teeth?YesNo

Have you been disappointed with the appearance of previous dental work?YesNo

Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)YesNo

Do you / would you have any problems chewing gum?YesNo

Do you / would you have any problems chewing bagels, baguettes , protein bars, or other hard foods?YesNo

Have your teeth changed in the last 5 years, become shorter, thinner or worn?YesNo

Are your teeth crowding or developing spaces?YesNo

Do you have more than one bite and squeeze to make your teeth fit together?YesNo

Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?YesNo

Do you clench your teeth in the daytime or make them sore?YesNo

Do you have any problems with sleep or wake up with an awareness of your teeth?YesNo

Do you wear or have you ever worn a bite appliance?YesNo

Have you had any cavities within the past 3 years?YesNo

Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?YesNo

Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?YesNo

Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?YesNo

Do you have grooves or notches on your teeth near the gum line?YesNo

Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?YesNo

Do you frequently get food caught between any teeth?YesNo

Do your gums bleed or are they painful when brushing or flossing?YesNo

Have you ever been treated for gum disease or been told you have lost bone around your teeth?YesNo

Have you ever noticed an unpleasant taste or odor in your mouth?YesNo

Is there anyone with a history of periodontal disease in your family?YesNo

Have you ever experienced gum recession?YesNo

Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?YesNo

Have you experienced a burning sensation in your mouth?YesNo

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