Dental History

Dental History

Name *

First Name

Last Name

Email Address *

Phone Number *

How do you feel about dental treatment?

Relaxed

A little uneasy

Tense

Anxious

Very Anxious

Have you seen a dentist before?

Yes

No

If so, when was your last dental visit?

Within the last 3 monthsWithin the last 3-6 monthsWithin the last 6-9 monthsWithin the last 9-12 monthsMore than 1 year agoMore than 2 years agoMore than 5 years agoNever

How would you rate your previous dental experience?

ExcellentGoodAveragePoor

What are your dental concerns?

Have you avoided regular dental care?

Yes

No

If so, why have you avoided regular dental care?

Are you happy with the appearance of your teeth?

Yes

No

If not, why are you unhappy with the appearance of your teeth?

How often do you brush?

Less than once per weekOnce per weekSeveral times per weekOnce per dayTwice per dayThree times per day

How often do you floss?

Less than once per weekOnce per weekSeveral times per weekOnce per dayTwice per dayThree times per day

How often do you use other aids?

Less than once per weekOnce per weekSeveral times per weekOnce per dayTwice per dayThree times per daywater flosser, gum picks, gum stimulator, etc.

Would you like your teeth to be whiter?

Yes

No

Would you like your teeth to be straighter?

Yes

No

Do you have, or have you ever had any of the following dental conditions? Please check all that apply. *

Aching or sensitive teeth

Active decay of teeth or gums

Areas of food traps

Bad breath

Broken filling

Broken or missing teeth

Cavities

Clicking or popping jaw

Cold sores

Difficulty opening wide

Dry mouth

Aesthetic concerns with teeth

Facial surgery

Gag easily

Growths or lesions in your mouth

Gum infection / disease

Gum treatments

Jaw pain or tiredness

Jaw clenching

Loose teeth

Night guard

Oral surgery

Orthodontic treatment

Sensitive or bleeding gums

Swelling or lumps in mouth

Swollen glands

Teeth grinding

Unfavorable dental experience

None of the above

Previous dentist or dental office

Name of previous dentist or dental office

City

Select a state / provinceAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaUS Virgin IslandsWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonDistrict of ColumbiaState / Province

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 status.

Signature *

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By providing a mobile number, I agree that the practice may send me automated appointment and dental marketing messages at the number I provided above. I understand my consent is not required for purchase.

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