DENTAL HISTORY FORM

Patient’s Name:

Patient’s E-mail:

Previous Dentist:

How Long?

Last Dental Visit:

Last Dental X-rays

How often do you have your teeth cleaned? 3 mo.4 mo.6 mo.1 year or longer

Why did you leave your last dentist?

What is your immediate dental concern?

How often do you brush?

floss?

Do you use any devices other than a manual brush and floss? YesNo

If yes specify:

ADDITIONAL INFORMATION

Please check YES or NO to each question. If unsure of a question, please consult with the dentist.

1. unhappy with the appearance of your teeth? YesNo
2. unfavourable dental experiences? YesNo
3. dental fears? YesNo
4. problems with effectiveness or bad reactions to dental anaesthetic? YesNo
5. orthodontic treatment (braces)? YesNo
6. periodontal (gum) treatment YesNo
7. bleeding, pain or swelling from gums? YesNo
8. loose or shifted teeth? YesNo
9. food traps between teeth? YesNo
10. growths or sore spots in your mouth? YesNo
11. teeth sensitive to heat, cold, sweets? YesNo
12. teeth sensitive to pressure? YesNo
13. avoid brushing any part of your mouth? YesNo
14. a burning sensation in your mouth? YesNo
15. difficulty swallowing? YesNo
16. unpleasant taste or odour in your mouth? YesNo
17. dry mouth? YesNo
18. jaw problems (temporomandibular joint)? YesNo
19. difficulty opening your mouth widely? YesNo
20. stiff neck muscles? YesNo
21. awaken with an awareness of your teeth and jaws? YesNo
22. tension headaches? YesNo
23. clench your teeth? YesNo
24. grind your teeth? YesNo
25. jaw clicking or popping? YesNo
26. do you wear a nightguard? YesNo
27. would you like your teeth to be whiter? YesNo

What do you like or dislike (or both) about your smile?

How nervous are you about dental treatment? Not at AllVery LittleModerately NervousNervousExtremely Nervous

SUPPLEMENTAL DENTURE/PARTIAL DENTURE HISTORY

(if you are wearing a partial or complete artificial denture please complete the following)

1. Has your present denture/partial been relined? YesNo
(when?)

2. Is your present denture/partial a problem? YesNo
(describe: )

3. Satisfied with the appearance? YesNo
4. Satisfied with the comfort? YesNo
5. Satisfied with the chewing ability? YesNo

When did you receive your first partial or complete denture?

How long have you worn your present denture?

RELEASE

I, the undersigned, certify that I have provided an accurate and complete personal dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my dental history. I understand that information provided from or to any other dental health care providers may be necessary, and I consent to the release of this information.

I have read and agree to the above release: Yes