Dental History FormIf you have any questions, please call our office at (204) 837-4517. Name * First Name Last Name Referred by * How would you rate the condition of your mouth? * Excellent Good Fair Poor Previous Dentist * How long have you been a patient? * Date of most recent dental exam * MM DD YYYY Date of most recent x-rays * MM DD YYYY Date of most recent treatment (other than a cleaning) * MM DD YYYY I routinely see my dentist every: * 3 Months 4 Months 6 Months 12 Months Not Routinely WHAT IS YOUR IMMEDIATE CONCERN? * PERSONAL HISTORY 1. Are you fearful of dental treatment? * Yes No 2. Have you had an unfavorable dental experience? * Yes No 3. Have you ever had complications from past dental treatment? * Yes No 4. Have you ever had trouble getting numb or had any reactions to local anesthetic? * Yes No 5. Did you ever have braces, orthodontic treatment or had your bite adjusted? * Yes No 6. Have you had any teeth removed? * Yes No SMILE CHARACTERISTICS 7. Is there anything about the appearance of your teeth that you would like to change? * Yes No 8. Have you ever whitened (bleached) your teeth? * Yes No 9. Have you felt uncomfortable or self conscious about the appearance of your teeth? * Yes No 10. Have you been disappointed with the appearance of previous dental work? * Yes No BITE AND JAW JOINT 11. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) * Yes No 12. Do you / would you have any problems chewing gum? * Yes No 13. Do you / would you have any problems chewing bagels, baguettes , protein bars, or other hard foods? * Yes No 14. Have your teeth changed in the last 5 years, become shorter, thinner or worn? * Yes No 15. Are your teeth crowding or developing spaces? * Yes No 16. Do you have more than one bite and squeeze to make your teeth fit together? * Yes No 17. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? * Yes No 18. Do you clench your teeth in the daytime or make them sore? * Yes No 19. Do you have any problems with sleep or wake up with an awareness of your teeht? * Yes No 20. Do you wear or have you ever worn a bite appliance? * Yes No TOOTH STRUCTURE 21. Have you had any cavities within the past 3 years? * Yes No 22. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any foods? * Yes No 23. Do you feel or notice any holes (i.e. pitting craters) on the biting surface of your teeth? * Yes No 24. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth? * Yes No 25. Do you have grooves or notches on your teeth near the gum line? * Yes No 26. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? * Yes No 27. Do you get food caught between any teeth? * Yes No GUM AND BONE 28. Do your gums bleed when brushing or flossing? * Yes No 29. Have you ever been treated for gum disease or been told you have lost bone around your teeth? * Yes No 30. Have you ever noticed an unpleasant taste or odor in your mouth? * Yes No 31. Is there anyone with a history of periodontal disease in your family? * Yes No 32. Have you ever experienced gum recession? * Yes No 33. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? * Yes No 34. Have you ever experienced a burning sensation in your mouth? * Yes No Patient's Signature * Date * Thank you!
