Dental History Form

SS/HIC/Patient ID#:

Name:

Email:

Date of Birth:

Street Address:

City:

State:

Zip:

Phone:

Date of Last Appointment:

Date of Last X-Rays:

Why did you leave your previous dentist:

Check the box next to the symptoms you have:

 Bad breath Bleeding gums Gums swollen or tender Sores, blisters, growths on lips or mouth Burning sensation on tongue Biting cheeks or lips Dry mouth Mouth breathing Chewing Swallowing Talking Prominent gag reflex Snoring Periodontal treatment Pyorrhea or trench mouth Orthodontic treatment Wisdom teeth extracted Bite problems Missing teeth Shifting position of teeth Chew on one side of mouth Tobacco use Chewing on foreign objects Fingernail biting Thumb sucking Tongue thrusting Pain on brushing teeth Loose or broken teeth Sensitivity to cold Sensitivity to hot Sensitivity to sweets Sensitivity when biting Stained teeth Grinding or clenching teeth Clicking or popping jaw Jaw pain or fatigue Opening or closing jaw Pain around ear

How often do you brush?:

How often do you floss?:

How often do you have your teeth cleaned?:

How often do you change toothbrushes?:

Patient Goals

What is your goal for dental treatment?:

Are you in discomfort today?: YesNo

Are you pleased with the appearance of your teeth?: YesNo

If no, please example:

Do you like your smile? YesNo

If no, please example:

Does dental treatment make you nervous? YesNo

If no, please example:

Have you been pleased with your previous dental care? YesNo

Have you ever had a bad experience in a dental office? If so, please explain:

How can we help improve your teeth and smile?