Dental Care Center

Dental History Forms

Please correct the errors described below.

Patient Information

First Name:

Middle Initial:

Last Name:

Dental History

Former Dentist:

Date of last exam:

Date of last X rays:

Reason for today’s visit:

How often do you brush?

How often do you floss or use picks?

Please choose any of the following conditions that apply to you:

Bad Breath

Bleeding gums

Clenching

Dry mouth

Food collection between teeth

Grinding teeth

Loose teeth/broken fillings

Jaw clicking/popping

Jaw pain

Periodontal treatment

Sensitivity to cold/hot

Sensitivity to biting/chewing

Sensitivity to sweet

Snoring

Sores or growths in mouth

Do you wear any of the following dental appliances:

Dentures or Partials

Orthodontic retainers

Mouth guard

Sleep appliance

Whitening trays

I have read my DENTAL HISTORY and confirm that it adequately states past and present conditions.

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

Signature:

Date:

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