Cary Office Click To Call
(919) 865-0700
1110 SE Cary Parkway Ste # 206
Cary, NC 27518, USA | Directions
Cornelius Office Click To Call
(704) 765-3150
20905 Torrence Chapel Rd #201
Cornelius, NC 28031, USA | Directions

Dental History

 Print blank form to fill by hand
Please note that it is important to fill in all the fields before submitting. Thank you.

*Last name :
*First name :
M.I :
1.Reason for today’s visit?
2.Are you aware of any problem?
3.How long since your last dental visit?
4.What was done at that time?
5.Previous dentist’s Name :
6.When was the last time your teeth were cleaned?
Select the appropriate answer. If you don't know the correct
answer, please select “Don't know”.
7.Have you made regular dental visits?YesNoDon't know
8.Were dental x-rays taken?YesNoDon't know
9.Have you lost any teeth or have any teeth been removed?YesNoDon't know
10.Have they been replaced?YesNODon't Know
11.How have they been replaced?
12.Are you happy with the replacement?YesNoDon't know
13.Would you like to know about permanent replacements?YesNoDon't know
14.Have you ever had any problems or complications with previous dental treatment?
15.Do you clench or grind your teeth?YesNoDon't know
16.Does your jaw pop or click?YesNoDon't know
17.Have you experienced any pain or soreness in the muscles in your face or around your ear?YesNoDon't know
18.Do you have frequent headaches, neckaches or shoulder aches?YesNoDon't know
19.Does food get caught in your teeth?YesNoDon't know
20.Are any of your teeth sensitive to:HotColdSweetsPressure
21.Do your gums bleed or hurt?YesNoDon't know
22.Have you ever had gum treatment or surgery?YesNoDon't know
23.Do you feel your breath is offensive at times?YesNoDon't know
24.How often do you brush your teeth daily?1X2X3XMore
When?
25.Do you use dental floss?YesNoDon't know
26.Are any of your teeth:LooseTippedShiftedChipped
27.Are you happy with the appearance of your teeth?YesNoDon't know
28.How do you feel about your teeth in general?
29.Have you had orthodontic work?YesNoDon't know
30.Have you had any unpleasant dental experiences or is there anything about dentistry that you strongly dislike?
31.Do you have any questions or concerns?YesNoDon't know
*I certify that the above information is complete and accurate.
*Patient's / Guardian's signature :
 Date :