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Dental History
First Name
Last Name
Date Of Birth
Referred by:
How would you rate the condition of your mouth?
Previous Dentist:
How long were you a patient of this dentist?
Date of most recent dental exam:
Date of most recent x-rays:
Date of most recent dental treatment (other than a cleaning)
I routinely see my dentist every:
What is your immediate concern?
PLEASE ANSWER YES OR NO TO THE FOLLOWING:
PERSONAL HISTORY
1) Are you fearful of dental treatment?
On a scale of 1 (least) to 10 (most)
2. Have you had an unfavorable dental experience?
Please tell us about that experience
3. Have you ever had complications from past dental treatment?
Please describe this complication.
4. Have you ever had trouble getting numb or had any reactions to local anesthetic?
Describe reaction
5. Did you ever have braces, orthodontic treatment or had your bite adjusted?
At what age?
6. Have you had any teeth removed or missing teeth that never developed or lost teeth due to injury or facial trauma?
Please specify:
GUM AND BONE
7. Do your gums bleed or are they painful when brushing or flossing?
8. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
When were you told or when did you have the treatment done?
9. Have you ever noticed an unpleasant taste or odor in your mouth?
10. Is there anyone with a histrory of periodontal (gum) disease in your family?
11. Have you ever experienced gum recession?
12. Have you ever had any teeth become loose on their own (without an injury) or do you have difficulty eating an apple?
13. Have you experienced a burning or painful sensation in your mouth not related to your teeth?
TOOTH STRUCTURE
14. Have you had any cavities within the past 3 years?
15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
18. Do you have grooves or notches on your teeth near the gum line?
19. Have you ever broken teeth, chipped teeth or had a toothahce or cracked fillings?
20. How you frequently get food caught between your teeth?
Where does the food get caught?
BITE AND JAW JOINT
21 .Do you have problems with your jaw joint?
Which problem?
22. Do you feel like your lower jaw is being pushed back when you bite your back teeth together?
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry food?
24. In the past 5 years, have your teeth changed (become shorter, thinner or worn) or has your bite changed?
25. Are your teeth becoming more crooked, crowed, or overlapped?
26. Are your teeth developing spaces or becoming loose?
27. 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?
28. Do you place your tongue between your teeth or close your teeth against your tongue?
29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
30. Do you clench or grind your teeth together in the daytime or make them sore?
31. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
32. Do you wear or have you ever worn a bite appliance?
When was it made?
SMILE CHARACTERISTICS
33. Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?
What would you like to change?
34. Have you ever whitened (bleached) your teeth?
When did you bleach them?
35. Have you felt uncomfortable or self conscious about the appearance of your teeth?
Please expand on the reasons why
36. Have you been disappointed with the appearance of previous dental work?
Please expand on what you didn't like
If you could have your ideal smile, what would that look like?
Would you like to see a photo of what your ideal smile could look like?
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