Dental History

Please complete the form below, and a member of our team will reach out if we have any questions. If you have any questions, please feel free to contact us.

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Dental History Form

Please fill out our dental history form in its entirety to ensure we can provide you with the best possible care.

Note: Any fields with * are required.

Patient Name *

First

Last

Email Address *

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 cleaning): *

What is your immediate concern? *

Please answer yes or no to the following.

Personal History

1. Are you fearful of dental treatment? *

2. Have you had an unfavorable dental experience? *

3. Have you had complications from past dental treatment? *

4. Have you ever had trouble getting numb or had any reactions to local anesthetic? *

5. Did you ever have braces, orthodontic treatment, or have your bite adjusted? *

6. Have you had any teeth removed? *

Smile Characteristics

1. Is there anything about the appearance of your teeth you would like to change? *

2. Have you ever whitened (bleached) your teeth? *

3. Have you felt uncomfortable or self-conscious about the appearance of your teeth? *

4. Have you been disappointed with the appearance of previous dental work? *

Bite & Jaw Joint

1. Do you have problems with your jaw joint (i.e., pain, sounds, limited opening, lock popping, etc.)? *

2. Do you/would you have any problems chewing gum? *

3. Do you/would you have any problems chewing bagels, baguettes, protien bars, or, other hard foods? *

4. Have your teeth changed in the last 5 years, become shorter, thinner or worn? *

5. Are your teeth crowding or developing spaces? *

6. Do you have more than one bite and squeeze to make your teeth fit together? *

7. Do you chew ice, bite your nails, use your teeth to hold objects or have any other oral habits? *

8. Do you clench your teeth in the daytime or do they become sore? *

9. Do you have any problems with sleep or wake up with an awareness of your teeth? *

10. Do you wear or have you ever worn a bite appliance? *

Tooth Structure

1. Have you had any cavities within the past 3 years? *

2. Does the amount of saliva in your mouth seem too little or do you have any difficulty swallowing any food? *

3. Do you feel or notice any holes (i.e. pitting, craters, etc.) on the biting surface of your teeth? *

4. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth? *

5. Do you have any grooves or notches on your teeth near the gum line? *

6. Have you ever had broken teeth, chipped teeth, or had a toothache, or cracked filling? *

7. Do you frequently get food caught between any teeth? *

Biology

1. Do your gums bleed or are they painful when brushing or flossing? *

2. Have you ever been treated for gum disease or been told you have lost bone around your teeth? *

3. Have you ever noticed an unpleasant odor in your mouth? *

4. Is there anyone with a history of periodontal disease in your family? *

5. Have you ever noticed gum recession? *

6. Have you ever had any teeth become loose on their own (no injury), or do you have difficulty eating an apple? *

7. Have you experienced a burning sensation in your mouth? *

Comment

Dental History

Dental History Form

Personal History

Smile Characteristics

Bite & Jaw Joint

Tooth Structure

Biology

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