Dental History

Please note that it is important to fill in all the fields before submitting. Thank you.
*Last name :
Middle name : *First name :
Please check any of the following problems that apply to you :
Sensitivity (hot, cold, sweet) Tooth pain or discomfort when chewing Headaches, ear aches, neck pain
Mouth ulcers or cold sores Jaw joint pain Broken tooth or fillings
Grinding or clenching teeth Bleeding, swollen or irritated gums Loose, tipped or shifted teeth
Bad breath or bad taste in your mouth
Do you have or have you had any of the following? Dentures     Partial dentures     Braces     Gum treatments
Required to take antibiotics prior to dental treatment
Previous Dentist Details:
Name :
City : State :
Phone #: ()--
Please share the following dates:
Your last cleaning :
Your last oral cancer screening :
Your last complete x-rays :
If you could whiten your teeth for a cost anyone could afford, would you do it?
Do you smoke or use chewing tobacco? How much? For how long?
If you could change your smile, you would:
Make my teeth whiter Make my teeth straighter
Close spaces Replace metal fillings with tooth colored fillings
Repair chipped teeth Replace missing teeth
Replace old crowns that don’t match Have a smile makeover
On a scale of 1 -10, with 10 being the highest rating:
How important is your dental health to you? 1 2 3 4 5 6 7 8 9 10
Where would you rate your current dental health? 1 2 3 4 5 6 7 8 9 10
Why did you leave your previous dentist?
What is the most important thing to you about your future smile and dental health?
What is the most important thing to you about your dental visit today?
*Signature :
Date :