Dental History Information
Are you happy with your smile? 0 Yes O No
Previous Dentist Name, City and Phone Number ( if known ):
Date of most recent dental exam and dental x-rays:
We want to serve you well! With that in mind, why did you leave you last dentist?
I have routinely seen my dentist every:
03mo. 04mo. 06mo.
Are you able to chew well? 0 Yes O No
Do you have TMJ pain? 0 Yes O No
D 12mo.
Do you have frequent headaches? 0 Yes O No
Are you very nervous about dental treatment? 0 Yes O No
What is the reason for your visit today?
Check all that apply:
D Not routinely
D Had complications from past dental treatment D Had trouble getting numb
D Had or have braces (orthodontic treatment) D Have dry mouth
D Food gets trapped between any teeth D Have whitened or bleached your teeth
D Clench or grind your teeth D Wear or have worn a bite appliance
D Have been treated for gum disease D Have or had gum recession
D Have or had a burning sensation in your mouth D Snore or wake up frequently during the night
If any of the checked boxes need further explanation, please describe:
Page 4 of 10
D Had any reactions to local anesthetic
D Teeth are sensitive to hot, cold, biting or sweets
D Have popping and/or clicking of your jaw joint
D Gums bleed when brushing or flossing
D Had an unpleasant taste or odor in your mouth
D Have dry mouth