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Dr. Travis Mattson
Dr. Timothy Obradovich
Dr. Haley Doose
Dr. Samuel Bander
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Pay Online
Contact
Request an Appointment
Home
About
Dr. Travis Mattson
Dr. Timothy Obradovich
Dr. Haley Doose
Dr. Samuel Bander
Meet the Team
Office Tour
Patient Video Testimonials
Services
Preventive Dentistry
Gum Disease Treatments
Dental Cleanings & Exams
Dental Hygiene
Composite Tooth Fillings
Dental Sealants
Fluoride Treatment
Oral Cancer Screenings
Cosmetic Dentistry
Dental Bonding
Porcelain Dental Veneers
Inlays & Onlays
Zoom Teeth Whitening
Teeth Whitening
Restorative Dentistry
Dental Bridges
Composite Fillings
Dental Crowns
Dental Implants
All-On-Four
Dentures
Additional Dentistry
Athletic Mouth Guards
Children’s Dentistry
Dental Emergencies
Night Guards
Sedation Dentistry
Sleep Apnea Treatment
TMD & TMJ Therapy
Wisdom Teeth Removal
Holistic Dentistry
Endodontics
Root Canal Therapy
Apicoectomy
Oral Surgery
Tooth Extraction
Crown Lengthening
Gum Grafting
Bone Grafting
Orthodontics
Invisalign
Aligners
Retainers
ClearCorrect
New Patients
Dental History Form
Medical History Form
Resources
Pay Online
Dental Emergency FAQ
Dental Technology
Smile Gallery
Educational Videos
Dental Blog
Pay Online
Contact
Request an Appointment
New Patient 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 exam
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Date of most recent x-rays
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Date of most recent treatment (other than a cleaning)
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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
Patient’s Signature (Typed)
Patient’s Signature (Freeform)
Date
MM slash DD slash YYYY
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