Download & Bring in Forms or Fill Online Dental History Form Download the printable PDF, fill it out, save and email to dr.pan@exceldental.ca Medical History Form Download the printable PDF, fill it out, save and email to dr.pan@exceldental.ca Dental History Name(Required) First Last NicknameAgeReferred byHow would you rate the condition of your mouth? Excellent Good Fair Poor Previous dentistHow long were you a patient?Date of most recent dental exam MM slash DD slash YYYY Date of most recent dental x-rays MM slash DD slash YYYY Date of most recent dental treatment MM slash DD slash YYYY (Other than cleanings)I routinely see my dentist every: 3 mos. 4 mos. 6 mos. 12 mos. Not frequently What is your immediate concern?Personal HistoryPlease Answer Yes or No to The Following:Are you fearful of dental treatment? Yes No How fearful, on a scale of 1 (least) to 10 (most)Have you had an unfavorable dental experience? Yes No ExplainHave you ever had complications from past dental treatment? Yes No ExplainHave you ever had trouble getting numb or had any reactions to local anesthetic? Yes No Did you ever have braces, orthodontic treatment or had your bite adjusted? Yes No Have you had any teeth removed or missing teeth that never developed? Yes No Gum and BonePlease Answer Yes or No to The Following:Do your gums bleed or are they painful when brushing or flossing? Yes No How OftenHave you ever been treated for gum disease or been told you have lost bone around your teeth? Yes No Have you ever noticed an unpleasant taste or odor in your mouth? Yes No Is there anyone with a history of periodontal disease in your family? Yes No Have you ever experienced gum recession? Yes No Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? Yes No Have you experienced a burning or painful sensation in your mouth not related to your teeth? Yes No Tooth StructurePlease Answer Yes or No to The Following:Have you had any cavities within the past 3 years? Yes No Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? Yes No Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? Yes No Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth? Yes No Do you have grooves or notches on your teeth near the gum line? Yes No Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? Yes No Do you frequently get food caught between any teeth? Yes No Bite and Jaw JointPlease Answer Yes or No to The Following:Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) Yes No Do you feel like your lower jaw is being pushed back when you bite your teeth together? Yes No Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? Yes No Have your teeth changed in the last 5 years, become shorter, thinner or worn? Yes No Are your teeth becoming more crooked, crowded, or overlapped? Yes No Are your teeth developing spaces or becoming more loose? Yes No Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together? Yes No Do you place your tongue between your teeth or close your teeth against your tongue? Yes No Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? Yes No Do you clench your teeth in the daytime or make them sore? Yes No Do you have any problems with sleep (i.e. restlessness), wake up with a headache or an awareness of your teeth? Yes No Do you wear or have you ever worn a bite appliance? Yes No Smile CharacteristicsPlease Answer Yes or No to The Following:Is there anything about the appearance of your teeth that you would like to change? Yes No Have you ever whitened (bleached) your teeth? Yes No Have you felt uncomfortable or self conscious about the appearance of your teeth? Yes No Have you been disappointed with the appearance of previous dental work? Yes No Patient SignatureName First Last Date MM slash DD slash YYYY Time Hours : Minutes AM PM AM/PM
