Dental history

Why have you come to the dentist today?

Why did you leave your previous dentist?

How can we accommodate you better during your dental visit?

Your current dental health is : Good Fair Poor

Date of last dental visit :

Last dental cleaning :

Last full mouth X-rays :

Are any of your teeth sensitive to:

Hot or cold?

Yes No

Sweets?

Yes No

Biting or Chewing?

Yes No

Have you noticed any mouth odors or bad tastes?

Yes No

Do you frequently get cold sores, blisters or any other oral lesions?

Yes No

Do your gums bleed or hurt?

Yes No

Have your parents experienced gum disease or tooth loss?

Yes No

Have you noticed any loose teeth or change in your bite?

Yes No

Does food tend to become caught in between your teeth?

Yes No

If yes, where?

Do you:

Clench or grind your teeth while awake or asleep?

Yes No

Bite your lips or cheeks regularly?

Yes No

Hold foreign objects with your teeth?
(pencils, pipe, pins, nails, fingernails)

Yes No

Mouth breathe while awake or asleep?

Yes No

Have tired jaws, especially in the morning?

Yes No

Snore or have any other sleeping disorders?

Yes No

Smoke/chew tobacco or use other tobacco products?

Yes No

Discolored/Stained teeth

Yes No

Crowding/Crooked teeth

Yes No

Missing teeth

Yes No

Spaces in between teeth

Yes No

Old fillings (gold or silver)

Yes No

Old crowns, bridge work (worn off, chipped, dark margin showing at your gum line)

Yes No

Too much gum tissue showing when smiling

Yes No

Have you ever had:

Orthodontic treatment?

Yes No

Oral Surgery?

Yes No

Periodontal treatment?

Yes No

Your teeth ground or the bite adjusted?

Yes No

A bite plate or mouth guard?

Yes No

A serious injury to the mouth or head?

Yes No

If so, please describe, including cause:

Have you experienced:

Clench or grind your teeth while awake or asleep?

Yes No

Clicking or popping of the jaw?

Yes No

Pain?(joint, ear, side of face)

Yes No

Difficulty in opening or closing the mouth?

Yes No

Difficulty in chewing on either side of the mouth?

Yes No

Headaches, neckaches or shoulder aches?

Yes No

Sore muscles (neck, shoulders)?

Yes No

Are you satisfied with your teeth’s appearance?

Yes No

Would you like to keep all of your teeth all of your life?

Yes No

Do you feel nervous about having dental treatment?

Yes No

If so, what is your biggest concern?

Have you whitened your teeth in the past?

Yes No

If so, please describe

Are you happy with your smile?

Yes No

Is there anything you would like to change about your smile (appearance of your teeth)?

Yes No

Have you ever had Botox or Juvederm?

Yes No

If so, please describe

Are you currently in pain?

Yes No

If so, please describe

Have you ever been pre-medicated for dental treatment?

Yes No

If so, please describe

Have you ever had an upsetting dental experience?

Yes No

If so, please describe

The information and preceding answers are true and correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or guardian to be necessary or advisable, including the use of local anesthesia and other medications as indicated. I agree that, regardless of insurance coverage, I am responsible for payment for services rendered. If I ever have any changes in my health or if my medication change I will, without fail, inform the doctor at my next appointment.

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Adult Patient Details

Insurance information

Medical History

Dental history