Dental History Form

    Client Name:
    Previous Dentist:

    Referred By:
    How Long:

    Last Dental Exam: (mm/dd/yyyy)

    Last Dental X-Ray: (mm/dd/yyyy)

    Last Dental Treatment: (mm/dd/yyyy)


    How often do you have your teeth cleaned?
    3 Months4 Months6 Months1 Year or longer

    What is your immediate dental concern?

    1. Are you presently having any discomfort or concerns about your mouth regarding:

    coldhotsweetpressurecheek bitesunpleasant breathchewingswellingbleedingtongue bitescanker soresunpleasant tastefood trapsfloss catchescold sores

    Are you experiencing:

    clenchingmuscle sorenessheadachesneck or shoulder paingrindingjoint problemsdifficulty openingmouth breathing, asleep / awake

    2. When you have attended other dental offices in the past what has actually happened?

    regular appt’steeth checkedfillingsx-raysorthodonticsinfrequent visitsgums checkedcrown & bridgedentureshome care inst.cleaningext’s surgeryfluorideroot canaldentisthygienist

    How did you feel about what was done?

    Any concerns (anxieties, phobias, etc.) regarding dental treatment?

    3. Tell me about your parents dentistry:

    4. Is it important to keep your teeth?

    5. Are silver mercury fillings a concern for you?

    6. Are you satisfied with the function of your teeth?

    7. Are you satisfied with the appearance of your teeth?

    8. Have you ever had an upsetting experience at the dental office?

    9. Have you ever had tooth brushing instruction?yesno

    10. Have you ever had flossing instruction? yesno

    Please verify your form submission by entering your full name and checking the box below.
    Please Enter Your Full Name:

    Please prove you are human by selecting the heart.