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Dental History

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Name
First Last
Nickname
Age
Referred by
How would you rate the condition of your mouth?
- Excellent
- Good
- Fair
- Poor
Previous Dentist
How long have you been a patient? (Months/Years)
Date of most recent dental exam
Date of most recent x-rays
Date of most recent treatment (other than a cleaning)
I routinely see my dentist every:
- 3 Months
- 4 Months
- 6 Months
- 12 Months
- Not Routinely
WHAT IS YOUR IMMEDIATE CONCERN?
PLEASE ANSWER YES OR NO TO THE FOLLOWING:
PERSONAL HISTORY
1. Are you fearful of dental treatment?
- Yes
- No
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 spaces?
- 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 frequently get food caught between any teeth?
- Yes
- No
GUM AND BONE
28. Do your gums bleed or are they painful 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

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