Submit Your Dental History

SECURE PATIENT FORM

Share information about past dental care, current concerns and treatment experiences before your visit.

HomeSubmit Your Dental History

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BEFORE YOU BEGIN

Have your health information ready before you begin.

Have your medication list, allergies and relevant health or dental information available. Contact the office if you are unsure how to answer a question.

Use accurate, current information
Do not submit another person’s information without permission
Call the office when information changes before the visit

Download printable PDF

Submit Your Dental History

Name(Required)

First Last

Nickname

Age

Referred by

How would you rate the condition of your mouth?

Excellent

Good

Fair

Poor

Previous dentist

How 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 History

Please Answer Yes or No to The Following:

Are you fearful of dental treatment?

Yes

How fearful, on a scale of 1 (least) to 10 (most)

Have you had an unfavorable dental experience?

Yes

Explain

Have you ever had complications from past dental treatment?

Yes

Explain

Have you ever had trouble getting numb or had any reactions to local anesthetic?

Yes

Did you ever have braces, orthodontic treatment or had your bite adjusted?

Yes

Have you had any teeth removed or missing teeth that never developed?

Yes

Gum and Bone

Please Answer Yes or No to The Following:

Do your gums bleed or are they painful when brushing or flossing?

Yes

How Often

Have you ever been treated for gum disease or been told you have lost bone around your teeth?

Yes

Have you ever noticed an unpleasant taste or odor in your mouth?

Yes

Is there anyone with a history of periodontal disease in your family?

Yes

Have you ever experienced gum recession?

Yes

Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?

Yes

Have you experienced a burning or painful sensation in your mouth not related to your teeth?

Yes

Tooth Structure

Please Answer Yes or No to The Following:

Have you had any cavities within the past 3 years?

Yes

Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

Yes

Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?

Yes

Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?

Yes

Do you have grooves or notches on your teeth near the gum line?

Yes

Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?

Yes

Do you frequently get food caught between any teeth?

Yes

Bite and Jaw Joint

Please Answer Yes or No to The Following:

Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

Yes

Do you feel like your lower jaw is being pushed back when you bite your teeth together?

Yes

Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?

Yes

Have your teeth changed in the last 5 years, become shorter, thinner or worn?

Yes

Are your teeth becoming more crooked, crowded, or overlapped?

Yes

Are your teeth developing spaces or becoming more loose?

Yes

Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together?

Yes

Do you place your tongue between your teeth or close your teeth against your tongue?

Yes

Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?

Yes

Do you clench your teeth in the daytime or make them sore?

Yes

Do you have any problems with sleep (i.e. restlessness), wake up with a headache or an awareness of your teeth?

Yes

Do you wear or have you ever worn a bite appliance?

Yes

Smile Characteristics

Please Answer Yes or No to The Following:

Is there anything about the appearance of your teeth that you would like to change?

Yes

Have you ever whitened (bleached) your teeth?

Yes

Have you felt uncomfortable or self conscious about the appearance of your teeth?

Yes

Have you been disappointed with the appearance of previous dental work?

Yes

Patient Signature

Name

First Last

Date

MM slash DD slash YYYY

Time

Hours

Minutes

AM/PM