Dental History Form

Patient Name

Date of Birth

Date of Last Dental Visit?

Reason for the Visit?

Date of Last Dental X-rays?

Former Dentist

Phone

Address

City

State

Zip

If you left your previous dentist, what was the reason?

What are your goals in coming to our practice today?

What is important to you in a dentist or dental practice?

At-Home Oral Hygiene Care

How often do you brush your teeth?

How often do you floss?

Do you use mouthwash?

Yes No

If yes, Which kind

Do you use any other dental home care products?

Yes No

If Yes, Which Kind

Select Appropriate Answer (Leave blank if you do not understand the questions)

1. Are you currently experiencing dental pain or discomfort?

Yes No

If Yes, Explain

2. Do your gums bleed?

Yes No

If Yes, Explain

3. Are your teeth loose?

Yes No

If Yes, Explain

4. Do you wear dentures or partials?

Yes No

If Yes, Explain

5. Have you ever been told you have gum disease?

Yes No

If Yes, Explain

6. Are your teeth sensitive to hot, cold, sweets or pressure?

Yes No

If Yes, Explain

7. Have your ever had any clicking, popping or discomfort in the jaw?

Yes No

If Yes, Explain

8. Do you brux or grind your teeth?

Yes No

If Yes, Explain

9. Do you wear an occlusal guard?

Yes No

10. Have you ever had orthodontic treatment (braces) before?

Yes No

If Yes, Explain

11. Do you have dry mouth?

Yes No

If Yes, Explain

12. Does food or floss catch between your feeth?

Yes No

If Yes, Explain

13. Have you had any problems or an upsetting dental experience associated with previous dental care?

Yes No

If Yes, Explain

14. Are you fearful of dentistry or have anxiety associated with dental treatment?

Yes No

If Yes, Explain

15. Have you ever been pre-medicated for dental treatment?

Yes No

If Yes, Explain

16. Have you ever had a reaction to anesthetic used with your dental treatment?

Yes No

If Yes, Explain

17. Are you happy with your smile?

Yes No

If No, Explain

18. What would you change about the present condition of your mouth?

19. Is there anything else you would like us to know about your dental health or dental history?

Yes No

If Yes, Explain

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful dental history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction.

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 of Patient (Parent or Guardian)

Date

Signature of Dentist

Date

Your information will be encrypted.