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.

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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: 
  

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x_______________________________                    Date:____________________________

Please Sign Here (Patient)

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