PATIENT DENTAL HISTORY INFORMATION
Date:
Patient Name (Last, First, MI):
Birth Date
%PatientNameLast%, %PatientNameFirst% %PatientNameMiddle%
(MM/DD/YYYY)
Prior Dentist / Dental Clinic Name:
City / State:
Last Dental Exam:
Last Dental Cleaning:
Last Dental XRay:
What is the reason for your dental visit today?
Explain:
Do you feel nervous about having dental treatment?
No
Yes
Are you currently experiencing tooth or jaw pain?
No
Yes
Is there anything you dislike about your smile?
No
Yes
Do your gums bleed when you brush or floss?
No
Yes
Are your teeth sensitive to cold, hot, sweets or pressure?
No
Yes
Is your mouth dry?
No
Yes
Have you had any periodontal (gum) treatment?
No
Yes
Have you had orthodontic (braces) treatment?
No
Yes
Do you wear a retainer?
No
Yes
Is your home water supply fluoridated?
No
Yes
Do you have headaches, earaches or neck pains?
No
Yes
Do you have any clicking, popping or discomfort in your jaw?
No
Yes
Do you clench or grind your teeth?
No
Yes
Do you wear a night guard?
No
Yes
Did you have your wisdom teeth removed?
No
Yes
Do you have sores or ulcers in your mouth?
No
Yes
Do you wear partials or dentures?
No
Yes
Have you ever had a serious injury to your head or mouth?
No
Yes
Do you suffer from sleep apnea?
No
Yes
Do you wear a night time device?
No
Yes