Dental History Form

Patient First Name: *

Patient Middle Name:

Patient Last Name: *

Patient Email: *

Home phone: *

Work phone:

Cell phone:

Previous Dentist:

Date of last dental visit(if not here):

What problems have you had with past dental treatments?:

How do you feel about the appearance of your teeth?

Do your gums bleed when you brush?

Have you had any periodontal treatment?

Have you had facial or gum swelling?

Do you experience any clicking or popping in your jaw?

Are you aware that you clench or grind your teeth?

Do you have headaches?

Do you have a nightguard, splint, snore guard?

I often catch food between my teeth:

I would like fresher breath:

I have or have had jaw pain (TMJ):

I clench or grind my teeth:

I have problems eating

I have had orthodontics

I feel that my teeth have shifted:

I avoid brushing part of my mouth due to pain:

My mouth often feels dry:

I prefer tooth colored fillings:

I smoke or use tobacco:

If yes, which brand?:

Do you use flossing aids (holder, threaders, etc.):

Do you use an oral irrigation device (Waterpik)?:

Do you use flouride treatments of supplements at home?

If so, which brand?

If so, which brand?

If yes, please specify: