Dental History

DENTAL HISTORY

Patient First Name

Middle Initial

Patient Last Name

Patient Birth Date

What is the reason for your dental visit today?

Previous Dentist

Location

Date of last dental visit

What was done at that time?

Date of last dental x-rays

Date of last professional dental cleaning

History of past dental cleanings

Every 3 months Every 6 months Once a year Other

Other

How often do you brush your teeth?

How often do you floss your teeth?

Are you currently experiencing dental pain or discomfort?

Yes No

If so, which tooth or area?

Please describe and rate your pain 1-10

Are your teeth sensitive to:

Cold Hot Sweets Pressure

Is your mouth dry?

Yes No

Do you clench or grind your teeth?

Yes No

Have you experienced any complications with dental treatment?

Have you been treated for gum disease or periodontitis?

Have you ever had a scaling/root planning or “deep cleaning”?

Yes No

If so, how long ago?

Do you have any other dental problems not listed?

Other Habits

Note: The American Dental Association recommends the use of professionally applied fluoride varnish every 3-6 months and the use of prescription fluoride toothpaste for patients with one or more risk factors listed above.

Alternative text

Do you have any existing crowns or bridges?

Yes No

Which tooth number or area(s)?

When was crown or bridge placed? (approximate if needed)

Month

Year

Do you have any additional crowns or bridges?

Yes No

Which tooth number or area(s)?

When was crown or bridge placed? (approximate if needed)

Month

Year

Do you have any additional crowns or bridges?

Yes No

Which tooth number or area(s)?

When was crown or bridge placed? (approximate if needed)

Month

Year

Do you have any existing dentures or partials?

Yes No

If yes:

Upper Lower

When were dentures made? (approximate if needed)

Month

Year

Have you ever worn braces or received orthodontic treatment?

Yes No

Are you unhappy with how your teeth look?

Yes No

If so, please describe

Do you have any other dental problems or conditions not addressed above?

Yes No

If so, please describe

FORM COMPLETION

Signature of Patient, Parent or Guardian:

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Date:

IF PATIENT IS A MINOR

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Relationship to Patient:

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