Dental and Oral Health Information
Please describe any specific dental problem or discomfort you are having at this time:
How long has it been present?
If you have had any of the following dental care please list the dentists and approximate dates:
Periodontal (gum) treatment or surgery
"Braces" or any other type of orthodontic treatment:
Any other types of oral surgery:
Do you have / have you had / have you noticed any of the following signs or symptoms in you head, neck or mouth?
( Please check Yes or No for each question)
Teeth that are sensitive to:
A clicking, snapping or difficulty when chewing
Hot, cold, sweets, or biting pressure
Difficulty opening or moving the jaws
An unpleasant taste or persistent bad breath
Difficulty speaking or changes in your voice
Does food catch between your teeth
Difficulty moving your tongue or "tongue tied"
Do your gums bleed when brushing
Loose or separating teeth
Red, swollen, tender, bleeding, or sore gums
Changes in the way your teeth fit together
Gums that have pulled away from the teeth
A color change of the tissues in your mouth
Pus between the teeth and gums
Pain, tenderness, numbness or earaches
Avoid any areas when brushing or chewing
Any lumps, swelling or swollen glands
You clench or grind your teeth
Sore, ulcers, rough spots in your mouth
Your Dental Health:
How do you rate your overall dental health?
How many times a
do you brush your teeth?
How many times a
do you floss your teeth?
Do you use any of the following?
(Please check Yes or No for each question)
Mechanical (electric) toothbrush? If Yes, what type or brand?
Flossing aids (floss holders, threaders, etc.)
Oral irrigation device (Waterpik)
Fluoride treatments or supplements at home? If Yes, which ones:
Mouthwashes or oral rinses? If Yes, which brand:
Do you have any missing teeth that have not been replaced
Why have you not had them replaced?
Do you wear any removeable dental appliances
If Yes, what type and for how long?
Have you ever has your teeth whitened or bleached?
Would you like to have your teeth whitened or bleached?
How do you feel about your appearance of your smile and what would you change if you could?
Are you concerned about the finances required to return your mouth to excellent health?
Are you frustrated becasue you always need something treated or repaired when you visit the dentist?
Do you feel you will eventually wear artifical dentures?
Have you ever had any complication from an extraction or dental treatment?
If yes, please explain:
Have you ever had any other dental condidtions, major trauma or injury to your head, neck, mouth?
If yes, please specify:
If you are new patient to this practice:
Date of last dental visit
City & State
Patient Validation: Please Enter Full Name