Dental History

Date of most recent dental exam:
Date of most recent dental exam:
Date of most recent x-rays:
Date of most recent x-rays:
Date of most recent treatment other than cleaning:
Date of most recent treatment other than cleaning:
May we request records from your previous dentistto help us facilitate care?
Personal History
Have you had an unfavorable dental experience?
Have you had complications from previous dental treaments?
Have you ever had trouble getting numb or reactions to local anesthetic?
Did you ever have braces, orthodontic treatment or had your bite adjusted?
Have you had any teeth removed?
Smile Characteristics
Is there anything about the appearance of your teeth you would like to change?
Have you ever whitened (bleached) your teeth?
Are you self-concious about your teeth?
Have you been disappointed with the appearance of previous dental work?
Bite and Jaw Joint:
Do you/would you have any problems chewing gum?
Do you/would you have any problems chewing bagels, or ther hard foods?
Have your teeth changed in the last 5 years, become shorter, thinner or worn?
Are your teeth crowding or developing spaces?
Do you have more than one bite or do you clench (squeeze) to make your teeth fit together?
Do you have problems with sleep or wake up with an awareness of your teeth?
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
Do you have tension headaches or sore teeth?
Do you wear or have you ever worn a bite appliance?
Tooth Structure:
Have you had any cavities within the past 3 years?
Do you have dry mouth?
Are any teeth sensitive to hot, cold, biting or sweets?
Have you ever had a toothache, cracked filling, broken, chipped or cracked tooth?
Do you avoid brushing any part of your mouth?
Do you feel or notice any holes (i.e. pitting) in your teeth?
Gum and Bone:
Have you ever been diagnosed or treated for periodontal (gum) disease?
Have you ever experienced gum recession?
Is there anyone with a history of periodontal disease in your family?
Do your gums bleed when brushing, flossing or eating?
Are your teeth becoming loose?
Have you ever noticed an unpleasant taste or odor in your mouth?
Have you experienced a burning sensation in your mouth? Yes
Today's date
Today's date
Signature of Patient, Responsible party
Signature of Patient, Responsible party