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 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 Months 4 Months 6 Months 12 Months Not Routinely
What is your immediate concern :
Are you fearful of dental treatments? Yes No
How fearful on a scale from 1(least) to 10 (most):
Have you had an unfavorable dental experience? Yes No
If so, briefly explain:
Have you ever had complications from past dental treatments? Yes No
Have you ever had trouble getting numb or had any reactions to local anesthetic? Yes No
Did you ever have braces, orthodontic treatment or had your bite adjusted? Yes No
If so, at what age?
Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma? Yes No
If so, briefly explain a little about it:
Do your gums bleed or are they painful when brushing or flossing? Yes No
Have you ever been treated for gum disease or been told you have lost bone around your teeth? Yes No
Have you ever noticed an unpleasant taste or odor in your mouth? Yes No
Is there anyone with a history of periodontal disease in your family? Yes No
Have you ever experienced gum recession? Yes No
Have you ever had any teeth become loose on their own(without an injury), or do you have difficulty eating an apple? Yes No
Have you experienced a burning or painful sensation in your mouth not related to your teeth? Yes No
Have you had any cavities within the past three years? Yes No
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? Yes No
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? Yes No
Are any teeth sensitive to hot, cold, biting, sweet, or do you avoid brushing any part of your mouth? Yes No
Do you have grooves or notches on your teeth near the gum line? Yes No
Have you ever broken teeth, chiped teeth, or had a toothache or cracked filling? Yes No
Do you frequently get food caught between any teeth? Yes No
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) Yes No
Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together? Yes No
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars or other hard dry foods? Yes No
In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed? Yes No
Are your teeth becoming more crooked, crowded or overlapped? Yes No
Are your teeth developing spaces or becoming more loose? Yes No
Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together? Yes No
Do you place your tongue between your teeth, or close your teeth against your tongue? Yes No
Do you chew ice, bite your nail, use your teeth to hold objects, or have any other oral habits? Yes No
Do you clench or grind your teeth together in the day time or make them sore? Yes No
Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache, or an awareness of your teeth? Yes No
Do you wear or have you ever worn a bite appliance? Yes No
Is there anything about the appearance of your teeth that you would like to change (shape, color, size)? Yes No
Have you ever whitened (bleached) your teeth? Yes No
Have you felt uncomfortable or self conscious about the appearance of your teeth? Yes No
Have you been disappointed with the appearance of previous dental work? Yes No
Patient's Signature (Please type your name. Your IP address will be collected to confirm and verify your signature):