Dental History
Patient Name
Nickname
Age
Referred by
How would you rate the condition of your mouth?
Excellent
Good
Fair
Poor
Previous Dentist
How long have you been the patient?
Month/Years
Date of most recent dental exam
-
Month
-
Day
Year
Date
Date of most recent x-rays
-
Month
-
Day
Year
Date
Date of most recent treatment (other than a cleaning)
-
Month
-
Day
Year
Date
I routinely see my dentist every
3 month
4 month
6 month
12 month
Not routinely
What is your immediate concern?
PLEASE ANSWER YES OR NO TO THE FOLLOWING QUESTIONS:
PERSONAL HISTORY
1. Are you fearful of dental treatment?
Yes
No
How fearful on a scale of 1 to 10
Least
1
2
3
4
5
6
7
8
9
Most
10
1 is Least, 10 is Most
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 & BONE
7. 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 bones 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 the 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 to your teeth?
Yes
No
TOOTH STRUCTURE
14. Have you had any cavities within past 3 years?
Yes
No
15. Does the amount of saliva in your mouth seem so 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 the teeth near your 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 POINT
21. Do you have problems with your jaw point? (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 gums, 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 you 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 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. restless or teeth grinding), wakeup 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 CHARACTERISTICS
33. Is there anything about the appearance of your mouth(smile, lips, teeth, gums) that you would like top change (shape, color, display, size)?
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
Patient Signature:
Date:
-
Month
-
Day
Year
Date
Submit
Should be Empty: