Dental History Form Patient InformationPatient Name First Last Email Address Date of Birth MM slash DD slash YYYY Referred by How would you rate the condition of your mouth? Excellent Good Fair Poor Previous Dentist How long have you been a patient? (Months/Years) Date of most recent dental exam MM slash DD slash YYYY Date of most recent x-rays MM slash DD slash YYYY Date of most recent treatment (other than a cleaning) MM slash DD slash YYYY I routinely see my dentist every 3 Months 6 Months 12 Months Not routinely WHAT IS YOUR IMMEDIATE CONCERN? Please answer YES or NO to the following questions:Personal History1. Are you fearful of dental treatment? Yes No 2. Have you had an unfavorable 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, and at what age? Yes No 6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma? Yes No GUM AND BONE7. Do your gums bleed sometimes or are they ever 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 anyone with a history of periodontal disease in your family? Yes No 11. Have you ever experienced gum recession, or can you see more of the roots of your teeth? Yes No 12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? Yes No 13. Have you experienced a burning or painful sensation in your mouth not related toyour teeth? Yes No TOOTH STRUCTURE14. 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 any food? Yes No 16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? Yes No 17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth? 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 filling? Yes No 20. Do you frequently get food caught between any teeth? Yes No BITE AND JAW JOINT21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) Yes No 22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together? Yes No 23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? Yes No 24. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed? 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 trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together? Yes No 28. Do you place your tongue between your teeth or close 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 or grind your teeth together in the daytime or make them sore? Yes No 31. Do you have any problems with sleep (i.e. restlessness or teeth grinding), 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 SMILE CHARACTERISTICS33. Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change(shape, color, size, display)? Yes No 34. Have you ever whitened (bleached) 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 SignatureSignature Δ
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