Dental History

Page 2 of 3

Patient Name:

Last Name

First Name

Initial

Birthdate:

Month Day

Year

E-mail Address:

Purpose of your initial visit?
Are you aware of a problem?
How long since your last visit?
What was done at that time?
When was your last teeth cleaning?

Who is your previous dentist's name?

Telehone:

() -

Address:

City:

State:

Zipcode:

Have you made regular visits?
How often?
Were dental X-rays taken?
Have you lost/removed any teeth?
If YES, explain:
Have they been replaced?

How have they been replaced?

Age

Unhappy with the replacement?
Problems with prior treatments?
If YES, explain:
Do you clench or grind your teeth?
Does your jaw click or pop?
Any pain in your muscles/face/ear?
Frequent headache/neckache/shoulder ache?
Does food get caught in your teeth?

Are your teeth sensitive to?

Do your gums bleed or hurt?
If YES, when:
How often do you brush?
When do you brush?
Do you use dental floss?
Do you have any loose/tipped/shifted/chipped teeth?
Are you unhappy with the appearance of your teeth?
How do you feel about your teeth in general?
Do you feel your teeth is offensive at times?
Have you ever had gum treatment or surgery?
What?
Where?
When?
Have you ever had orthodontic work?
Have you had unpleasant dental experiences or strongly dislike anything about dentistry?
Do you have any concerns or questions?

Release:

I certify that the above information is complete and accurate

Patient/Parent's Signature _________________________________________________________ Date: _______________________

Dentist's Signature _________________________________________________________ Date: _______________________