Please enable JavaScript in your browser to complete this form.Dental History FormLayoutPatient Name *Patient Nickname *Age *Layout (copy)Referred byHow would you rate the condition of your mouth?ExcellentGoodFairPoorLayoutPrevious Dentist OptionalHow long have you been a patient?LayoutDate of most recent dental examIf anyDate of most recent x-raysIf anyDate of most recent treatment (other than a cleaning) If anyI routinely see my dentist every *3 month4 month6 month12 monthNot routinelyWHAT IS YOUR IMMEDIATE CONCERN?PLEASE ANSWER YES OR NO TO THE FOLLOWING:PERSONAL HISTORYLayout1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) Yes/NoYESNoLayout2. Have you had an unfavorable dental experience? Yes/NoYESNoLayout3. Have you ever had complications from past dental treatment? Yes/NoYESNoLayout4. Have you ever had trouble getting numb or had any reactions to local anesthetic? Yes/NoYESNoLayout5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age? Yes/NoYESNoLayout6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma? Yes/NoYESNoGUM AND BONELayout7. Do your gums bleed sometimes or are they ever painful when brushing or flossing? Yes/NoYESNoLayout8. Have you ever had or been told you have gum disease, gum or bone loss between your teeth, or had scaling and root planing? Yes/NoYESNoLayout9. Have you ever noticed an unpleasant taste or odor in your mouth? Yes/NoYESNoLayout10. Is there anyone with a history of periodontal disease in your family? Yes/NoYESNoLayout11. Have you ever experienced gum recession, or can you see more of the roots of your teeth? Yes/NoYESNoLayout12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? Yes/NoYESNoLayout13. Have you experienced a burning or painful sensation in your mouth not related to your teeth? Yes/NoYESNoTOOTH STRUCTURELayout14. Have you had any cavities within the past 3 years? Yes/NoYESNoLayout15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? Yes/NoYESNoLayout 16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? Yes/NoYESNoLayout17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth? Yes/NoYESNoLayout18. Do you have grooves or notches on your teeth near the gum line? Yes/NoYESNoLayout19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? Yes/NoYESNoLayout20. Do you frequently get food caught between any teeth? Yes/NoYESNoBITE AND JAW JOINTLayout21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) Yes/NoYESNoLayout22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together? Yes/NoYESNoLayout23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? Yes/NoYESNoLayout24. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed? Yes/NoYESNoLayout25. Are your teeth becoming more crooked, crowded, or overlapped? Yes/NoYESNoLayout26. Are your teeth developing spaces or becoming more loose? Yes/NoYESNoLayout27. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together? Yes/NoYESNoLayout28. Do you place your tongue between your teeth or close your teeth against your tongue? Yes/NoYESNoLayout29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? Yes/NoYESNoLayout30. Do you clench or grind your teeth together in the daytime or make them sore? Yes/NoYESNoLayout31. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth? Yes/NoYESNoLayout32. Do you wear or have you ever worn a bite appliance? Yes/NoYESNoSMILE CHARACTERISTICSLayout33. Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size, display)? Yes/NoYESNoLayout34. Have you ever bleached (whitened) your teeth? Yes/NoYESNoLayout35. Have you felt uncomfortable or self conscious about the appearance of your teeth? Yes/NoYESNoLayout36. Have you been disappointed with the appearance of previous dental work? Yes/NoYESNoLayoutPatient’s Signature *Clear SignaturePlease Sign HereDate *Doctor’s SignatureClear SignaturePlease Sign HereDate Submit
