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