Dental History

Patient Name

Nickname

Age

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

I routinely see my dentist every

3 mo. 4 mo. 6 mo. 12 mo. Not routinely

WHAT IS YOUR IMMEDIATE CONCERN?

PLEASE ANSWER YES OR NO TO THE FOLLOWING:

PERSONAL HISTORY

1. Are you fearful of dental treatment?

How fearful, on a scale of 1 (least) to 10 (most)

2. Have you had an unfavorable dental experience?

3. Have you ever had complications from past dental treatment?

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

5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?

6. Have you had any teeth removed, missing teeth that never developed, or lost teeth due to injury or facial trauma?

GUM AND BONE

7. Do your gums bleed sometimes or are they ever uncomfortable when brushing or flossing?

8. Have you ever had or been told you have gum loss, gum disease, or bone loss between your teeth?

9. Have you ever noticed an unpleasant taste, odor in your mouth, or swollen and puffy gums?

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

11. Have you ever experienced gum recession, or can you see more of the roots of your teeth?

12. Have you ever had any teeth become loose on their own (without an injury), or feel them move when chewing?

13. Have you experienced a burning, painful sensation, or metallic taste in your mouth?

TOOTH STRUCTURE

14. Have you had any cavities within the past 3 years?

15. Does the amount of saliva in your mouth seem too little, not enough, or do you have difficulty swallowing or chewing any food?

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

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

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

19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?

20. Do you frequently get food caught between any teeth?

21. Does your jaw joint ever have pain, sounds (popping, cracking), or experience limited opening or locking?

22. Do you feel like you need to pull your lower jaw back, or feel that it is being pushed back when you try to bite your back teeth together?

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

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

25. Are your teeth becoming more crooked, crowded, or overlapped?

26. Are your teeth developing spaces or becoming more loose?

27. Do you have more than one bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together better?

28. Do you place your tongue between your teeth or close your teeth against your tongue?

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

30. Do you clench or grind your teeth together in the daytime / nighttime or ever make them sore?

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

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

SMILE CHARACTERISTICS

33. Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (color, spaces, size, shape, display)?

34. Have you ever bleached (whitened) your teeth?

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

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

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.

Patient’s Signature

Date

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