Dental History Form Fill Out Our Dental History Form Below Patient Name* 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? Date of most recent dental examMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of most recent x-raysMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Date of most recent treatment (other than a cleaning)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920I 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 HISTORY1. Are you fearful of dental treatment? YES NO How fearful, on a scale of 1 (least) to 10 (most) - Comment 2. Have you had an unfavorable dental experience? YES NO Unfavorable dental experience - Comment 3. Have you ever had complications from past dental treatment? YES NO Had complications from past dental treatment - Comment 4. Have you ever had trouble getting numb or had any reactions to local anesthetic? YES NO Trouble getting numb - Comment 5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age? YES NO Trouble getting numb Comment / Age 6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma? YES NO Teeth removed or facial trauma - Comment GUM AND BONE7. Do your gums bleed sometimes or are they ever painful when brushing or flossing? YES NO Gums bleed - Comment 8. Have you ever been treated for gum disease or been told you have lost bone around your teeth? YES NO Gums bleed - Comment 9. Have you ever noticed an unpleasant taste or odor in your mouth? YES NO Unpleasant mouth odor - Comment 10. Is there anyone with a history of periodontal disease in your family? YES NO History of periodontal disease in your family - Comment 11. Have you ever experienced gum recession? YES NO Have you ever experienced gum recession - Comment 12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? YES NO Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple - Comment 13. Have you experienced a burning or painful sensation in your mouth not related to your teeth? YES NO Have you experienced a burning or painful sensation in your mouth not related to your teeth - Comment TOOTH STRUCTURE14. Have you had any cavities within the past 3 years? YES NO Have you had any cavities within the past 3 years - Comment 15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? YES NO Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food - Comment 16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? YES NO Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth - Comment 17. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth? YES NO Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth - Comment 18. Do you have grooves or notches on your teeth near the gum line? YES NO Do you have grooves or notches on your teeth near the gum line - Comment 19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? YES NO Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling - Comment 20. Do you frequently get food caught between any teeth? YES NO Do you frequently get food caught between any teeth - Comment TOOTH STRUCTURE14. Have you had any cavities within the past 3 years? YES NO Have you had any cavities within the past 3 years - Comment 15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? YES NO Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food - Comment 16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? YES NO Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth - Comment 17. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth? YES NO Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth - Comment Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth YES NO Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth - Comment 18. Do you have grooves or notches on your teeth near the gum line? YES NO Do you have grooves or notches on your teeth near the gum line - Comment 19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? YES NO Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling - Comment 20. Do you frequently get food caught between any teeth? YES NO Do you frequently get food caught between any teeth - Comment BITE AND JAW JOINT21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) YES NO Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) - Comment 22. Do you feel like your lower jaw is being pushed back when you bite your teeth together? YES NO Do you feel like your lower jaw is being pushed back when you bite your teeth together - Comment 23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? YES NO Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods- Comment 24. Have your teeth changed in the last 5 years, become shorter, thinner or worn? YES NO Have your teeth changed in the last 5 years, become shorter, thinner or worn - Comment 25. Are your teeth becoming more crooked, crowded, or overlapped? YES NO Are your teeth becoming more crooked, crowded, or overlapped - Comment 26. Are your teeth developing spaces or becoming more loose? YES NO Are your teeth developing spaces or becoming more loose - Comment 27. Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together? YES NO Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together - Comment 28. Do you place your tongue between your teeth or close your teeth against your tongue? YES NO Do you place your tongue between your teeth or close your teeth against your tongue - Comment 29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? YES NO Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits - Comment 31. Do you have any problems with sleep (i.e. restlessness), wake up with a headache or an awareness of your teeth? YES NO Do you have any problems with sleep (i.e. restlessness), wake up with a headache or an awareness of your teeth - Comment 32. Do you wear or have you ever worn a bite appliance? YES NO Do you wear or have you ever worn a bite appliance - Comment SMILE CHARACTERISTICS32. Do you wear or have you ever worn a bite appliance? YES NO Do you wear or have you ever worn a bite appliance - Comment 33. Is there anything about the appearance of your teeth that you would like to change? YES NO Is there anything about the appearance of your teeth that you would like to change - Comment 34. Have you ever whitened (bleached) your teeth? YES NO Have you ever whitened (bleached) your teeth - Comment 35. Have you felt uncomfortable or self conscious about the appearance of your teeth? YES NO Have you felt uncomfortable or self conscious about the appearance of your teeth - Comment 36. Have you been disappointed with the appearance of previous dental work? YES NO Have you been disappointed with the appearance of previous dental work - Comment Patient’s Signature (Typed) Patient’s Signature (Freeform)Date MM slash DD slash YYYY CAPTCHA
