Dental History

Adult or Child

Adult Child

Patient First Name

Middle Name

Last Name

Parent or Guardian's Name

Reason for your initial visit

Are you aware of a problem?

How long since your dental visit?

What was done at that time?

Name and location of previous dentist

How long has it been since your teeth were cleaned?

Did you have regular visits with your dentist? How often?

How long has it been since dental x-rays were taken?

Have you lost teeth or had teeth removed? If so, why?

Have any lost teeth been replaced? If so, how?

Describe any problems or complications you have had with previous dental treatments

Do you clench or grind your teeth?

Yes No

Do you experience dry mouth?

Yes No

Have you had any orthodontic work?

Yes No

Does your jaw click or pop?

Yes No

Do you floss daily?

Yes No

Are you experiencing any pain or sensitivity?

Yes No

Do you require antibiotics before treatment?

Yes No

How often do you brush your teeth?

How often do you replace your tooth brush?

Would you like whiter teeth?

Yes No

Do your gums ever bleed?

Yes No

Have you ever had periodontal disease?

Yes No

Are you happy with how your teeth look?

Yes No

Is there anything else we should know about your teeth?

Responsible Party's Full Name

________________________________________
Responsible Party's Signature (to be signed at time of first visit)

____________________
Date

Is this your child's first visit to a dentist?

Yes No

Were any x-rays or radiographs taken when your child previously visited the dentist?

Yes No

Does your child eat between meals?

Yes No

Does your child eat sweets such as candy, gum, or sugary drinks?

Yes No

When does your child brush his/her teeth? Check all that apply.

After waking up

After eating any food

Right after meals

Before going to bed

How does your child receive fluoride?

Municipal water

Fluoride drops or tablets

Well water

Fluoride rinse or gel

What Level in ppm?

for municipal water

What Level in ppm?

for well water

Have any cavities been noted in the past?

Yes No

Does your child suck his/her thumb or fingers?

Yes No

Were any teeth (baby or permanent) removed by extraction?

Yes No

Was is suggested that the space be maintained?

Yes No

Was an appliance placed?

Yes No

Have there been any injuries to any teeth, such as falls, blows, chips. etc?

Yes No

Please describe

Has your child had any problems with dental treatment in the past?

Yes No

Please describe

Has anyone in the family, including parents, had orthodontics?

Yes No

Has your child ever received local anesthetic?

Yes No

Has your child ever had occlusal sealants?

Yes No

Does your child think there is anything wrong with his/her teeth?

Yes No

Please describe

Parent of Guardian's First Name

Middle Name

Last Name

_________________________________________
Parent or Guardian's Signature (to be signed at time of first visit)

_________________
Date

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Dental History

Penfield Family Dentistry