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Dental History

Patient Name
Date of Last Dental Visit?
Last Dental Cleaning?
Last Full Mouth X-Rays
Previous Dentist's Name
Address
Have you ever used or are you currently using topical fluoride?
Do you have dental problems now?
Are your teeth sensitive to:
Are your teeth sensitive to:
  Yes No
Hot or Cold?
Sweets?
Biting or chewing?
Have you noticed mouth odors or bad taste?
Do you frequently get cold sores, blisters, or any other oral lesions?
Do your gums bleed or hurt?
Have you or your parents experienced gum disease or tooth loss?
Have you noticed any loose teeth or change in your bite?
Have you ever had:
Have you ever had:
  Yes No
Orthodontic treatment?
Oral surgery?
Periodontal treatment?
Your teeth ground or the bite adjusted?
A bite plate or mouth guard?
A serious injury to the mouth ?
Do you:
Do you:
  Yes No
Clinch or grind your teeth?
Bite your lips or cheeks regularly?
Hold foreign objects with your teeth (pencils, pipe, pins, nails, fingernails)?
Mouth breathe while awake or asleep?
A bite plate or mouth guard?
A serious injury to the mouth ?
Smoke/chew tobacco or use other tobacco products?

Medical History

Medical History
Check any past/current patient problems
Do You Use Tobacco?
Are you currently taking supplements or prescription medication?
Prescribing Doctor's Name
Do you suffer from any known allergies?
What causes you allergic reactions?
Have you had any surgeries in the past 5 years?
Are you pregnant or think you could be pregnant?
Today's Date
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