Patient Forms

Dental History

Patient Name

Nickname

Date of Birth (Format: yyyy-mm-dd)

Your Email

Referred by

How would you rate the condition of your mouth?
ExcellentGoodFairPoor

Previous Dentist

How long have you been a patient?

MonthsYears

Date of your most recent dental exam (Format: yyyy-mm-dd)

Date of your most recent x-rays (Format: yyyy-mm-dd)

Date of your most recent treatment, other than cleaning (Format: yyyy-mm-dd)

I routinely see my dentist every
3 months4 months6 months12 monthsNot routinely

What is your immediate concern?

Personal History

1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)
12345678910

2. Have you had an unfavorable dental experience?
YesNo

3. Have you ever had complications from past dental treatment?
YesNo

4. Have you ever had trouble getting numb or had any reactions to local anesthetic?
YesNo

5. Did you ever have braces, orthodontic treatment or had your bite adjusted?
YesNo

6. Have you had any teeth removed?
YesNo

Smile Characteristics

7. Is there anything about the appearance of your teeth that you would like to change?
YesNo

8. Have you ever whitened (bleached) your teeth?
YesNo

9. Have you felt uncomfortable or self conscious about the appearance of your teeth?
YesNo

10. Have you been disappointed with the appearance of previous dental work?
YesNo

Bite and Jaw Joint

11. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
YesNo

12. Do you/would you have any problems chewing gum?
YesNo

13. Do you/would you have any problems chewing bagels, baguettes, protein bars, or other hard foods?
YesNo

14. Have your teeth changed in the last 5 years, become shorter, thinner or worn?
YesNo

15. Are your teeth crowding or developing spaces?
YesNo

16. Do you have more than one bite and squeeze to make your teeth fit together?
YesNo

17. Do you chew ice, bite your nails, use your teeth to hold object, or have any oral habits?
YesNo

18. Do you clench your teeth in the daytime or make them sore?
YesNo

19. Do you have any problems with sleep or wake up with an awareness of your teeth?
YesNo

20. Do you wear or have you ever worn a bite appliance?
YesNo

Tooth Structure

21. Have you had any cavities within the past 3 years?
YesNo

22. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
YesNo

23. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
YesNo

24. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
YesNo

25. Do you have grooves or notches on your teeth near the gum line?
YesNo

26. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
YesNo

27. Do you frequently get food caught between any teeth?
YesNo

Gum and Bone

28. Do your gums bleed or are they painful when brushing or flossing?
YesNo

29. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
YesNo

30. Have you ever noticed an unpleasant taste or odor in your mouth?
YesNo

31. Is there anyone with a history of periodontal disease in your family?
YesNo

32. Have you ever experienced gum recession?
YesNo

33. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
YesNo

34. Have you experienced a burning sensation in your mouth?
YesNo

Complete