DENTAL HISTORY
Name:
Referred by:
How would you rate the condition of your mouth?
Excellent
Good
Fair
Poor
Previous Dentist:
How long have you been a patient?:
Date of most recent medical exam:
Date of most recent x-rays:
I routinely see my dentist every:
3 mo.
4 mo.
6 mo.
12 mo.
Not routinely
WHAT IS YOUR IMMEDIATE CONCERN?
:
PLEASE ANSWER THE FOLLOWING
YES
NO
PERSONAL HISTORY
1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most):
Yes
No
2. Have you had an unfavorable dental experience?
Yes
No
3. Have you ever had complications from past dental treatment?
Yes
No
4. Have you ever had trouble getting numb or had any reactions to local anesthetic?
Yes
No
5. Did you ever have braces, orthodontic treatment or had your bite adjusted?
Yes
No
6. Have you had any teeth removed?
Yes
No
SMILE CHARACTERISTICS
7. Is there anything about the appearance of your teeth that you would like to change?
Yes
No
8. Have you ever whitened (bleached) your teeth?
Yes
No
9. Have you felt uncomfortable or self conscious about the appearance of your teeth?
Yes
No
10. Have you been disappointed with the appearance of previous dental work?
Yes
No
BITE AND JAW JOINT
11. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)?
Yes
No
12. Do you / would you have any problems chewing gum?
Yes
No
13. Do you / would you have any problems chewing bagels, baguettes, protein bars, or other hard foods?
Yes
No
14. Have your teeth changed in the last 5 years, become shorter, thinner or worn?
Yes
No
15. Are your teeth crowding or developing space?
Yes
No
16. Do you have more than one bite and squeeze to make your teeth fit together?
Yes
No
17. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
Yes
No
18. Do you clench your teeth in the daytime or make them sore?
Yes
No
19. Do you have any problems with sleep or wake up with an awareness of your teeth?
Yes
No
20. Do you wear or have you ever worn a bite appliance?
Yes
No
TOOTH STRUCTURE
21. Have you had any cavities within the past 3 years?
Yes
No
22. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
Yes
No
23. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
Yes
No
24. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?
Yes
No
25. Do you have grooves or notches on your teeth near the gum line?
Yes
No
26. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
Yes
No
27. Do you get food caught between any teeth?
Yes
No
GUM AND BONE
28. Do your gums bleed when brushing or flossing?
Yes
No
29. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
Yes
No
30. Have you ever noticed an unpleasant taste or odor in your mouth?
Yes
No
31. Is there anyone with a history of periodontal disease in your family?
Yes
No
32. Have you ever experienced gum recession?
Yes
No
33. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
Yes
No
34. Have you experienced a burning sensation in your mouth?
Yes
No
Patients Signature:
Date:
Doctors Signature:
Date:
Patient Validation:
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