Dental History Form

Patient Name

Age

Referred By

Previous Dentist’s Name

How Long?

Date of Most Recent Exam?

I See My Dentist

What is your immediate concern?

On a scale of 1-10 (10 greatest), how important is your dental health?

On a scale of 1-10 (10 greatest), how would you rate your current dental health?

On a scale of 1-10 (10 greatest), how fearful are you of dental treatment?

Personal History

Have you had an unfavorable dental experience?

Have you ever had complications from past dental treatment?

Have you ever had trouble getting numb or had any reactions to local anesthesia?

Do you have, or have you had any teeth removed or teeth that never developed?

Did you ever have orthodontic treatment, braces, or your bite adjusted?

Gum/Bone History - Periodontal

Do your gums bleed or do they hurt during brushing/flossing?

Have you ever been told you have gum disease or are losing bone around your teeth?

Have you ever noticed an unpleasant taste/smell in your mouth?

Does anyone in your family have a history of periodontal/gum disease?

Have you experienced gum recession (teeth look longer)?

Have you ever had any teeth become loose on their own?

Tooth Structure History - Cavities

Have you had any cavities within the past 3 years?

Does the amount of your saliva in your mouth seem to little or do you have trouble eating/swallowing food?

Do you feel or notice any holes on the tops of your teeth?

Are your teeth sensitive to hot, cold, biting, sweets, etc or do you avoid brushing any area?

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

Have you ever broken, chipped, cracked any teeth or had a toothache?

Do you get food caught between your teeth?

Occlusion History - Bite, Jaw & TMJ

Do you have problems with your jaw joint? (pain, popping, cracking, locking, etc.)

Do you avoid chewing gum, carrots, nuts, hard or chewy foods?

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

Are your teeth becoming more crooked, crowded, or overlapped?

Are your teeth developing spaces or becoming loose?

Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together?

Do you clench your teeth during the day or night or wake with a headache?

Do you wear, or have you ever worn, a bite appliance?

Cosmetic History - Smile

Is there anything about your appearance of your teeth that you would like to change?

Have you ever whitened/bleached your teeth?

Have you felt uncomfortable or self-conscious about the appearance of your teeth?

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

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Dental History Form

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