Dental History Form First Name * Required First Last Name * Required Last Phone * RequiredEmail * Required How would you rate the condition of your mouth? * RequiredExcellentGoodFairPoorPrevious Dentist * Required Date of Last Dental Exam MM slash DD slash YYYY Date of Most Recent X-Rays MM slash DD slash YYYY I routinely see my dentist every * Required3 months4 months6 months12 monthsNot routinelyPersonal HistoryAre you fearful of dental treatment? How fearful, on a scale of 1(Least) to 10 (most) * Required Have you had an unfavorable dental experience? * Required Have you ever had complications from past dental treatment? * Required Have you ever had trouble getting numb or had any reactions to local anesthetic? * Required Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age? * Required Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma? * Required Gum and BoneDo your gums bleed sometimes or are they ever painful when brushing or flossing? * Required Have you ever been treated for gum disease, had scaling and root planing, or been told you have lost bone around your teeth? * Required Have you ever noticed an unpleasent taste or odor in your mouth? * Required Is there anyone with a history of periodontal disease in your family? * Required Have you ever experienced gum recession, or can you see more of the roots of your teeth? * Required Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? * Required Have you experienced a burning or painful sensation in your mouth not related to your teeth? * Required Tooth StructureHave you had any cavities within the past 3 years? * Required Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? * Required Do you feel or notice any holes (i.e pitting, craters) on the biting surface of your teeth? * Required Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth? * Required Do you have grooves or notches on your teeth near the gum line? * Required Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? * Required Do you frequently get food caught between any teeth? * Required Bite and Jaw JointDo you have problems with your jaw joint? (Pain, sounds, limited opening, locking, popping) * Required Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together? * Required Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? * Required In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed? * Required Are your teeth becoming more crooked, crowded, or overlapped? * Required Are your teeth developing spaces or becoming more loose? * Required Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together? * Required Do you place your tongue between your teeth or close your teeth against your tongue? * Required Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? * Required Do you clench or grind your teeth together in the daytime or make them sore? * Required Do you have any problems with sleep (i.e restlessness or teeth grinding), wake up with a headache or an awareness of your teeth? * Required Do you wear or have you ever worn a bite appliance? * Required Smile CharacteristicsIs there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (Shape, color, size, display) * Required Have you ever bleached (whitened) your teeth? * Required Have you felt uncomfortable or self conscious about the appearance of your teeth? * Required Have you been disappointed with the appearance of previous dental work? * Required
