Dental History Please fill out all the information to the best of your knowledge. All answers will be kept confidential. If you have any questions, please ask us, and we'll be happy to assist you. Birth Date: What other dental aids do you use? Electric ToothBrush Manual Toothbrush Soft Medium Hard Toothpick Flouride Rinse Other Have you received any formal oral hygiene instrucions? Yes No Do you like your smile? Yes No Are you interested in straightening your teeth (orthodontic treatment)? Yes No Have you had braces before? Yes No Please circle YES or NO to indicate if you have had or currently have any of the following: Gag easily Yes No Avoid brushing because of pain Yes No Notice slow-healing sores in mouth Yes No Your jaw makes noise OR gets stuck Yes No Earaches or pain in front of your ears Yes No Habitually chew gum Yes No Gums bleed easily Yes No Discomfort with HOT foods/liquids Yes No Clench or grind your teeth frequently Yes No Temporamandibular jaw disorder Yes No Take fluoride supplements Yes No Difficulty chewing Yes No Gums bleed when flossing Yes No Discomfort with COLD food or liquids Yes No Pain in face, cheeks, jaw joints Yes No Chew on only one side of your mouth Yes No Gums feel swollen or tender Yes No Discomfort with SWEET or SOUR foods Yes No Discomfort when chewing Yes No Have trauma to the jaw Yes No If you could change your smile, what would you like to change? (please check) The color of my teeth The shape of my teeth The position or alignment of my teeth Close spaces or restore worn and broken teeth I'm interested in (please check) Teeth Whitening Straight Teeth Replacement of missing teeth White fillings Breath control A serious injury to the mouth or head Yes No Food collection between teeth Yes No Oral Surgery (Extractions) Yes No Endodontic Treatment (Root Canals) Yes No Periodontal Treatment (Gums- Deep Cleaning) Yes No If yes, Please indicate: Osseous Surgery Tissue Gingival Grafts Tissue Management (Scaling, Curetage) Do you feel nervous about having dental treatment? Yes No Have you ever had an upsetting dental experience? Yes No Do you have any other concerns about your mouth? Yes No 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. Date: Submit Form Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.
