Dental History Patient Name Last Name First Name Middle Name Last Dental Visit? What is the reason for your visit today? Last Dental Cleaning Last Full Mouth X-rays What was done at your last dental visit? Previous Dentist’s Name How often do you have dental examinations? How often do you brush your teeth? How often do you floss? Have you ever used or are you currently using topical fluoride? NoYes Do you have any dental problems now? NoYes If yes, please describe: Are you sensitive to Hot or cold? NoYes Are you sensitive to sweets, biting, or chewing? NoYes Have you noticed any mouth odors or bad taste? NoYes Do you frequently get cold sores, blisters or any other oral lesions? NoYes Do your gums bleed or hurt? NoYes Have your parents experienced gum disease or tooth loss? NoYes Does food tend to become caught in between your teeth? NoYes Have you noticed any loose teeth or change in your bite? NoYes If yes, where? Have you ever had: Orthodontic treatment? NoYes Oral surgery? NoYes Periodontal treatment? NoYes A serious injury to the mouth or head? NoYes Pain (joint, ear, side of face)? NoYes Difficulty in opening or closing the mouth? NoYes Clicking or popping of the jaw? NoYes Headaches, neck aches or shoulder aches? NoYes Sore muscles (neck, shoulders)? NoYes Are you satisfied with your teeth’s appearance? NoYes Would you like to keep all of your teeth all of your life? NoYes Do you feel nervous about having dental treatment? NoYes Difficulty in chewing on either side of the mouth? NoYes Have you ever had an upsetting dental experience? NoYes If so, what is your biggest concern? Clench or grind your teeth while awake or asleep? NoYes How Did You Hear About Us? Mouth breathe while awake or asleep? NoYes If yes, please describe Smoke/chew tobacco or use other tobacco products? NoYes Bite your lips or cheeks regularly? NoYes Hold foreign objects with your teeth (pencils, pipe, pins, nails, fingernails)? NoYes Have tired jaws, especially in the morning? NoYes Snore or have any other sleeping disorders? NoYes Have you ever been told to take a pre-medication prior to dental treatment? NoYes Is there anything else about having dental treatment that you would like us to know? NoYes If yes, please describe
