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