Dental History




Referred By:

How would you rate the condition of your mouth:

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:

What is your immediate concern :

Personal History

Are you fearful of dental treatments?

How fearful on a scale from 1(least) to 10 (most):

Have you had an unfavorable dental experience?

If so, briefly explain:

Have you ever had complications from past dental treatments?

If so, briefly explain:

Have you ever had trouble getting numb or had any reactions to local anesthetic?

If so, briefly explain:

Did you ever have braces, orthodontic treatment or had your bite adjusted?

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?

If so, briefly explain a little about it:

Gum and Bone

Do your gums bleed or are they painful when brushing or flossing?

Have you ever been treated for gum disease or been told you have lost bone around your teeth?

Have you ever noticed an unpleasant taste or odor in your mouth?

Is there anyone with a history of periodontal disease in your family?

Have you ever experienced gum recession?

Have you ever had any teeth become loose on their own(without an injury), or do you have difficulty eating an apple?

If so, briefly explain a little about it:

Have you experienced a burning or painful sensation in your mouth not related to your teeth?

If so, briefly explain a little about it:

Tooth Structure

Have you had any cavities within the past three years?

Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?

Are any teeth sensitive to hot, cold, biting, sweet, or do you avoid brushing any part of your mouth?

Do you have grooves or notches on your teeth near the gum line?

Have you ever broken teeth, chiped teeth, or had a toothache or cracked filling?

Do you frequently get food caught between any teeth?

Bite and Jaw Joint

Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?

Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars or other hard dry foods?

In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?

Are your teeth becoming more crooked, crowded or overlapped?

Are your teeth developing spaces or becoming more loose?

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?

Do you place your tongue between your teeth, or close your teeth against your tongue?

Do you chew ice, bite your nail, use your teeth to hold objects, or have any other oral habits?

Do you clench or grind your teeth together in the day time or make them sore?

Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache, or an awareness of your teeth?

Do you wear or have you ever worn a bite appliance?

Smile Characteristics

Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?

If so, briefly explain a little about it:

Have you ever whitened (bleached) your teeth?

Have you felt uncomfortable or self conscious about the appearance of your teeth?

Have you been disappointed with the appearance of previous dental work?

Patient's Signature (Please type your name. Your IP address will be collected to confirm and verify your signature):