Dental History Name First Last Age Referred byHow would you rate the condition of your mouth?ExcellentGoodFairPoorPrevious DentistHow long have you been a patient?Date of most recent dental exam Date of most recent x-rays Date of most recent treatment (other than a cleaning) I routinely see my dentist every:3 month4 month6 month12 monthNot routinelyWHAT IS YOUR IMMEDIATE CONCERN?PLEASE ANSWER YES OR NO TO THE FOLLOWING:PERSONAL HISTORYAre you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)Have you had an unfavorable dental experience?YesNoHave you ever had complications from past dental treatment?YesNoHave you ever had trouble getting numb or had any reactions to local anesthetic?YesNoDid you ever have braces, orthodontic treatment or had your bite adjusted?YesNoHave you had any teeth removed or missing teeth that never developed?YesNoGUM AND BONEDo your gums bleed or are they painful when brushing or flossing?YesNoHave you ever been treated for gum disease or been told you have lost bone around your teeth?YesNoHave you ever noticed an unpleasant taste or odor in your mouth?YesNoIs there anyone with a history of periodontal disease in your family?YesNoHave you ever experienced gum recession?YesNoHave you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?YesNoHave you experienced a burning or painful sensation in your mouth not related to your teeth?YesNoTOOTH STRUCTUREHave you had any cavities within the past 3 years?YesNoDoes the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?YesNoDo you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?YesNoAre any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?YesNoDo you have grooves or notches on your teeth near the gum line?YesNoHave you ever broken teeth, chipped teeth, or had a toothache or cracked filling?YesNoDo you frequently get food caught between any teeth?YesNoBITE AND JAW JOINTDo you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)YesNoDo you feel like your lower jaw is being pushed back when you bite your teeth together?YesNoDo you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?YesNoHave your teeth changed in the last 5 years, become shorter, thinner or worn?YesNoAre your teeth becoming more crooked, crowded, or overlapped?YesNoAre your teeth developing spaces or becoming more loose?YesNoDo you have more than one bite, squeeze, or shift your jaw to make your teeth fit together?YesNoDo you place your tongue between your teeth or close your teeth against your tongue?YesNoDo you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?YesNoDo you clench your teeth in the daytime or make them sore?YesNoDo you have any problems with sleep (i.e. restlessness), wake up with a headache or an awareness of your teeth?YesNoDo you wear or have you ever worn a bite appliance?YesNoSMILE CHARACTERISTICSIs there anything about the appearance of your teeth that you would like to change?YesNoHave you ever whitened (bleached) your teeth?YesNoHave you felt uncomfortable or self conscious about the appearance of your teeth?YesNoHave you been disappointed with the appearance of previous dental work?YesNoCAPTCHA
