Patient Account No.:

Medical Alert:

Reason for visit today:

Date of Last Dental Visit:

Last Dental Cleaning:

Last Full Mouth X-rays:

What was done at your last dental visit?

Previous Dentist’s Name:

Address:

Telephone:

How often do you have dental examinations?

How often do you brush your teeth?

How often do you floss?

Other dental aids you use:

Do you have any dental problems now?SelectYesNo
If yes, please describe:

Are your teeth sensitive to:
Hot or cold? Sweets? Biting or chewing?

Have you noticed:
Mouth odors/bad taste? Cold sores/blisters? Other oral lesions?

Do your gums bleed or hurt?
Do your parents have gum disease?
Loose teeth or bite changes?

Does food get caught between teeth?
If yes, where?

Do you:
Clench/grind teeth? Bite lips/cheeks? Hold objects in your teeth? Mouth breathe? Have tired jaws in the morning? Smoke/chew tobacco?

Have you ever had:
Orthodontic treatment? Oral surgery? Periodontal treatment? Bite adjusted or mouth guard? Head or jaw injury? If yes, describe:

Have you experienced:
Clicking/popping of jaw? Joint pain? Difficulty chewing? Neck/shoulder pain? Sore muscles?

Are you satisfied with the appearance of your teeth?
Would you like to keep all your teeth for life?
Do you feel nervous about dental treatment?
If yes, what is your biggest concern?

Have you had a bad dental experience?
If yes, please describe:

Anything else you’d like us to know?

Submit