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Dental History
Patient's Legal Name:
required
First Name
Last Name
Date of Birth:
required
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 dental exam:
Date of most recent x-rays:
Date of most recent treatment (other than a cleaning):
I routinely see my dentist every:
3 mo.
4 mo.
6 mo.
12 mo.
Not routinely
What is your immediate concern?
PLEASE ANSWER YES OR NO TO THE FOLLOWING:
PERSONAL HISTORY
Are you fearful of dental treatment?
No
Yes
How fearful on a scale of 1 (least) to 10 (most)
1
2
3
4
5
6
7
8
9
10
Have you had an unfavorable dental experience?
No
Yes
Have you ever had complications from past dental treatment?
No
Yes
Have you ever had trouble getting numb or had any reactions to local anesthetic?
No
Yes
Have you had any teeth removed or missing teeth that never developed?
No
Yes
GUM AND BONE
Do your gums bleed or are they painful when brushing or flossing?
No
Yes
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
No
Yes
Have you ever noticed an unpleasant taste or odour in your mouth?
No
Yes
Is there anyone with a history of periodontal disease in your family?
No
Yes
Have you ever experienced gum recession?
No
Yes
Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
No
Yes
Have you experienced a burning or painful sensation in your mouth not related to your teeth?
No
Yes
TOOTH STRUCTURE
Have you ever had any cavities within the last 3 years?
No
Yes
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
No
Yes
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
No
Yes
Are any teeth sensitive to hot, cold, biting sweets, or avoid brushing any part of your mouth?
No
Yes
Do you have grooves or notches on your teeth near the gum line?
No
Yes
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
No
Yes
Do you frequently get food caught between any teeth?
No
Yes
BITE AND JAW JOINT
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
No
Yes
Do you feel like your lower jaw is being pushed back when you bite your teeth together?
No
Yes
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
No
Yes
Have your teeth changed in the last 5 years, become shorter, thinner or worn?
No
Yes
Are your teeth becoming more crooked, crowded, or overlapped?
No
Yes
Are your teeth developing spaces or becoming more loose?
No
Yes
Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together?
No
Yes
Do you place your tongue between your teeth or close your teeth against your tongue?
No
Yes
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
No
Yes
Do you clench your teeth in the daytime or make them sore?
No
Yes
Do you have any problems with sleep? (i.e. restlessness), wake up with a headache or an awareness of your teeth?
No
Yes
Do you wear or have you ever worn a bite appliance?
No
Yes
SMILE CHARACTERISTICS
Is there anything about the appearance of your teeth that you would like to change?
No
Yes
Have you ever whitened (bleached) your teeth?
No
Yes
Have you ever felt uncomfortable or self-conscious about the appearance of your teeth?
No
Yes
Have you been disappointed with the appearance of previous dental work?
No
Yes
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