Dental History Name * First Name Last Name Email * Phone (###) ### #### How do you feel about dental treatment? Relaxed A little uneasy Tense Anxious Very Anxious Have you seen a dentist before? Yes No If so, when was your last dental visit? Within the last 3 months Within the last 3-6 months Within the last 6-9 months More than 1 year ago More than 2 year ago More than 5 year ago Never How would you rate your previous dental experience? Excellent Good Average Poor What are your dental concerns? Have you avoided regular dental care? Yes No If so, why have you avoided regular dental care? Are you happy with the appearance of your teeth? Yes No If not, why are you unhappy with the appearance of your teeth? How often do you brush? Less than once per week Once a week Several times per week Once per day Twice per day Three times per day How often do you floss? Less than once per week Less than twice per week Several times per week Once per day Twice per day Three times per day Would you like your teeth to be whiter? Yes No Would you like your teeth to be straighter? Yes No Do you have, or have you ever had any of the following dental conditions? Please check all that apply. * Aching or sensitive teeth Areas of food traps Broken filling Cavities Cold sores Dry mouth Facial surgery Growths or lesions in your mouth Gum treatments Jaw clenching Night guard Orthodontic treatment Swelling or lumps in mouth Teeth grinding Active decay of teeth or gums Bad breath Broken or missing teeth Clicking or popping jaw Difficulty opening wide Aesthetic concerns with teeth Gag easily Gum infection / disease Jaw pain or tiredness Loose teeth Oral surgery Sensitive or bleeding gums Swollen glands Unfavorable dental experience None of the above Previous dentist or dental office To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in status. * Signature Thank you!
