Dental History Form


The information provided on this form is important to your dental health. Please complete all of questions to the best of your ability. If there have been any changes in your health, please tell us. Questions are welcome and appreciated.


The security of your information is very important to us. This form is fully secure and your information will be protected. To learn more about the security measures used on this form, click the security logo to the right.


Contact Information

Patient First Name: *

Patient Middle Name:

Patient Last Name: *

Patient Email: *

Home phone: *

Work phone:

Cell phone:


Dental History

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?

Yes No  

Have you had any periodontal treatment?

Yes No  

Have you had facial or gum swelling?

Yes No  

Do you experience any clicking or popping in your jaw?

Yes No  

Are you aware that you clench or grind your teeth?

Yes No  

Do you have headaches?

Yes No  

Do you have a nightguard, splint, snore guard?

Yes No  


I often catch food between my teeth:

Yes No  

I would like fresher breath:

Yes No  

I have or have had jaw pain (TMJ):

Yes No  

I clench or grind my teeth:

Yes No  

I have problems eating

Yes No  

I have had orthodontics

Yes No  

I feel that my teeth have shifted:

Yes No  

I avoid brushing part of my mouth due to pain:

Yes No  

My mouth often feels dry:

Yes No  

I prefer tooth colored fillings:

Yes No  

I smoke or use tobacco:

Yes No  


Do you use a mechanical (electric) toothbrush?

  Yes   No  

If yes, which brand?:


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

Yes No  

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

Yes No  

Do you use flouride treatments of supplements at home?

Yes No  

If so, which brand?

Do you use mouthwashes or oral rinses?

  Yes   No  

If so, which brand?

Have you ever had any complications from an extraction or dental treatment?

  Yes   No  

If yes, please specify:


Have you been bothered by?

Tooth pain

Dry mouth

Uneven bite

Tooth color/appearance

Rough / sharp tooth surface

Bad breath


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WEO Media, 8625 SW Cascade Avenue Suite 300, Beaverton, OR, 97008 - Tags: dental marketing : dental SEO : dental websites : (888) 788-4670 : : 7/20/2019