Patient Dental History

Please check any of the following that apply to you.

Currently experiencing dental pain/discomfort

Sensitivity to cold, heat or sweets

Headaches, earaches, neck pain

Jaw joint pain

Teeth or Filling Breaking

Grinding or clenching of teeth

Bleeding, swollen or irritated gums

Loose, tipped or shifting teeth

If Sensitivity to cold, heat or sweets is checked, where? (UR LR UL LL )

Do you have or have you had any of the following?

Dentures

Partial dentures

Braces

Periodontal (gum) treatments

Please share the following dates:

Your last dental cleaning

Your last oral cancer screening

Your last complete X-rays

Name of Previous Dentist

Why did you leave?

What did you like most about your last dentist?

If yes, How much

If yes, How long?

If i could change my smile, I would

Make them whiter

Make them straighter

Close spaces

Replace black metal fillings with tooth colored restorations

Repair chipped teeth

Replace old crowns that don't match

Have a smile makeover

On a scale from 1 - 10 with 10 being the highest rating

What is your most important question or concern about your dental visit today?

MEDICAL HISTORY

If Other, Please specify

If yes, Please Explain

Physician's Name

Phone

Please list any medications you are currently taking

Treatment Authorization Form

I hereby authorize and give consent to perform dental services agreed upon between doctor and patient and/or parent or guardian, after a thorough explanation and to be necessary and advisable, including any diagnostic aids deemed appropriate by the doctor and the use of local anesthesia and other medication as indicated. I certify the above statements regarding my dental health and medical condition. Payment for all services rendered is my responsibility.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature (Patient, Parent or Responsible Party)

Relationship to Patient

Date

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