Dental History Form | Grand Rapids MI Dentists

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 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

1. 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 BONE

7. 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 STRUCTURE

14. 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 STRUCTURE

14. 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 JOINT

21. 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 CHARACTERISTICS

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

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

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PLEASE ANSWER YES OR NO TO THE FOLLOWING:

PERSONAL HISTORY

GUM AND BONE

TOOTH STRUCTURE

TOOTH STRUCTURE

BITE AND JAW JOINT

SMILE CHARACTERISTICS