Dental form

Patient

Age

REASON FOR VISIT AND DENTAL HISTORY

1. What can we do for you? (Example: 'Check up and cleaning','I want my teeth to look nice', 'I have a hard time chewing'...)

2. When was your last visit to the dentist for a truly complete, detail and accurate examination?

3. Do you remember the name of your previous dentist? (We will NOT contact your previous dentist. If you dont know, please leave blank)

4. At your last exam, was there some work that had not been completed or things that were left to “monitor”?

5. How often do you usually have your dental exam?

6. Is there any particular reason why you are changing dentist?

7. On a scale from 0 to 10, what is your level of fear or anxiety about dentistry?

8. Is there something in particular that worries you or bother you at the dentist?

TEETH

10. Does food get stuck between the teeth or do flossing breaks or holds on to certain places?
yesno

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Explain

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11. Do you have fillings that have fallen or have cracked?
yesno

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Explain

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GUM

12. Do your gums bleed (even a little)?yesno

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When?
while brushingwhile flossing

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13. How often on average do you brush and floss your teeth?

Brushing

Flossing

Mouthwash

Any other equipment? ('waterflosser, interdental brushes')

14. To your knowledge, are there a family member who has had gum disease?
yesno

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Explain

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15. Are you unconfident of your breath or is there occasional bad taste in your mouth?
yesno

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Explain

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TEETH FUNCTION

16. Do you restrain yourself from chewing hard food?
yesno

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Explain

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17. Do you feel like you grind or clench your teeth?
yesno

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Explain

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18. Do you feel like it does not close equal?
yesno

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Explain

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19. Are your teeth worn out, cracked or transparent?
yesno

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Explain

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20. Does your jaw locks, crack or makes noise when you chew or yawn?
yesno

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Explain

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21. Are your teeth or jaw are sensitive in the morning?
yesno

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Explain

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ESTHETIC

22. Have you had orthodontic treatment (braces) and what are / were the retentions?
yesno

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Explain

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23. Are you satisfied with the appearance of your teeth esthetically or there is something you would like to improve?
yesno

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Explain

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24. Do your teeth have been whitened?
yesno

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When?

How?

25. Are you satisfied with the result?
yesno

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Explain

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OTHER

26. Is there something else you want to discuss?
yesno

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Explain

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