Dental History- Adult

This form collects information regarding an adult patient's dental history, oral health, oral hygiene habits, previous dental treatment experiences and desired dental treatments.





Dental History Adult


Why are you changing your dentist? ________________________
How long ago was your last visit to your dentist?  
1 month/ 3 months/ 6 months/ 1 year/ 2 years/ 3 years/ More than 3 years/ I've never seen a dentist
Name of previous dentist ________________________
How did you find us?  
Other Patient/ Dental Office/ Yelp/ Google/ Internet/ Yellow Pages/ Mailer/ Work/ School/ Insurance Co/ Other
Reason for today's visit:  

[x] Check-up

[x] Pain

[x] Cleaning

[x] Other

Have you ever had a bad experience at the dentist? ________No/Yes________
Have you had any complications following treatment? ________No/Yes________
Have you had any unfavorable reactions to dental anesthetic? ________No/Yes________
Does dental treament make you nervous?  
No/ Yes/ Slightly/ Yes, Moderately/ Yes Extremely
Are your teeth sensitive to cold or hot temperatures? ________No/Yes________ 
Do your gums bleed when you brush or floss? ________No/Yes________ 
Do you grind your teeth? ________No/Yes________ 
Are you aware of sores or irritated areas in the mouth? ________No/Yes________ 
Have you ever been treated for Periodontal Disease? ________No/Yes________ 
How often do you brush?  
Never/ Occasionally/ Once a day/ Twice a day/ Three times a day/ Every time I eat
How often do you floss?  
Never/ Occasionally/ Once a day/ Twice a day/ Three times a day/ Every time I eat
Do you like your smile? ________No/Yes________ 
If you could change your smile, what would you like to change? 

[x] Change the color of my teeth   

[x] Change the shape of my teeth   

[x] Other   

[x] Close spaces or restore worn out or broken teeth

[x] Change the position or alignment of my teeth


I am interested in  

[x] Teeth whitening   

[x] Straight teeth   

[x] Home care   

[x] Cosmetic evaluation   

[x] Sedation   

[x] Breath control   

[x] Replacement of missing teeth

[x] White fillings

[x] Other

To ensure your visit is a great experience, please share any questions or concerns you would like us to know about: 





x_______________________________                    Date:____________________________

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