Dental History

First Name

Last Name

Date of Birth

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Do you need to pre-medicate for dental appointments?

Yes No

If yes, what type of antibiotic have you historically used (i.e. amoxicillin, etc.)?

Do you...

Have teeth sensitivity to hot, cold or pressure?

Yes No

Have bleeding gums?

Yes No

Experience food catching between your teeth?

Yes No

Have spaces developing between your teeth?

Yes No

Clench or grind your teeth?

Yes No

Experience jaw cracking, popping, or discomfort when you when you open or close your mouth?

Yes No

Have a history of orthodontic treatment (braces)?

Yes No

Have a history of any periodontal (gum) treatment?

Yes No

Have a history of unfavorable dental experiences?

Yes No

Have concerns about the appearance of your teeth?

Yes No

Like the color of your teeth?

Yes No

Have the desire to change the appearance of your teeth if you could?

Yes No

Have old ﬁllings or previous dental treatment that is no longer satisfactory to you?

Yes No

What type of dental homecare products do you use?

Please tell us about any other problems, concerns or questions that you would like to have addressed. We will do our best to listen attentively to your concerns so we can present you with the best possible treatment options.

When was your last…

Dental Exam

Last dental cleaning

Bitewing x-rays*

Full mouth series of x-rays*

Panoramic x-ray*

* It will be of utmost importance to know when your last dental x-rays were taken, if unsure please call your previous dental health provider to inquire. To avoid need for additional x-rays to be taken and associated charges incurred, please make sure to bring recent x-rays with you. Bitewings are considered recent if less than 1-year old, full mouth series and panoramic x-rays are considered recent if less than 5-years old.

FORM COMPLETION

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Signature of:

Patient Legal Guardian Parent Agent Under Durable Power of Attorney

Signature of Patient, Parent or Guardian

Clear

Clear

Date

IF PATIENT IS A MINOR

Form signed by

Relationship to Patient

Dental History

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