Request an Appointment
COVID 19 Safety Protocols
(616) 531-0360
COVID 19 Safety Protocols
Home
About
Meet the Dentists
Meet the Staff
Before & After Gallery
Patient Testimonials
Services
Preventive Dentistry
Periodontal Deep Cleanings
Gum Disease Treatments
Fluoride Treatments
Oral Examinations
Dental Sealants
Oral Cancer Screening
Cosmetic Dentistry
Invisalign®
Cosmetic Bonding
Composite Fillings
Porcelain Veneers
Dental Crowns
Teeth Whitening
Zoom Teeth Whitening
Restorative Dentistry
Porcelain Bridges
Dentures
Dental Implants
Root Canal Therapy
Tooth Extractions
Inlays & Onlays
Additional Dental Services
Botox®
Dental Technology
Night Guards
Oral Surgery
Sedation Dentistry
Snoring & Sleep Apnea Devices
Sports Dentistry
TMD, MPD, & TMJ Treatment
Dental Emergencies
Children
Resources
Safety & Visits
COVID-19 Safety Protocols
Appointments
Patient Forms
Dental Blog
Financial Policy
Pay Online
Dental Educational Videos
Safety & Visits
COVID-19 Safety Protocols
Contact
Request an Appointment
(616) 531-0360
Home
About
Meet the Dentists
Meet the Staff
Before & After Gallery
Patient Testimonials
Services
Preventive Dentistry
Periodontal Deep Cleanings
Gum Disease Treatments
Fluoride Treatments
Oral Examinations
Dental Sealants
Oral Cancer Screening
Cosmetic Dentistry
Invisalign®
Cosmetic Bonding
Composite Fillings
Porcelain Veneers
Dental Crowns
Teeth Whitening
Zoom Teeth Whitening
Restorative Dentistry
Porcelain Bridges
Dentures
Dental Implants
Root Canal Therapy
Tooth Extractions
Inlays & Onlays
Additional Dental Services
Botox®
Dental Technology
Night Guards
Oral Surgery
Sedation Dentistry
Snoring & Sleep Apnea Devices
Sports Dentistry
TMD, MPD, & TMJ Treatment
Dental Emergencies
Children
Resources
Safety & Visits
COVID-19 Safety Protocols
Appointments
Patient Forms
Dental Blog
Financial Policy
Pay Online
Dental Educational Videos
Safety & Visits
COVID-19 Safety Protocols
Contact
Request an Appointment
(616) 531-0360
Adult Dental History Form
Adult Dental History Form
Patient Name:
Patient Email:
Date of Birth:
Date Format: MM slash DD slash YYYY
Patient Phone:
How would you rate the condition of your mouth?
Excellent
Good
Fair
Poor
How frequently do you get your teeth cleaned?
3mo
4mo
6mo
12mo
Not Routinely
Previous dentist:
How long have you been a patient?
Date of most recent dental exam:
Date Format: MM slash DD slash YYYY
Date of most recent x-rays:
Date Format: MM slash DD slash YYYY
What is your immediate concern?
PERSONAL HISTORY
Are you fearful of dental treatment? How fearful on a scale of 1 (least) to 10 (most)
Yes
No
If Yes:
Have you had an unfavorable dental experience?
Yes
No
Have you ever had complications from past dental treatment?
Yes
No
Have you ever had trouble getting numb or had any reactions to local anesthetic?
Yes
No
Did you ever have braces, orthodontic treatment or had your bite adjusted?
Yes
No
Have you had any teeth removed?
Yes
No
SMILE CHARACTERISTICS
Is there anything about the appearance of your teeth that you would like to change?
Yes
No
Have you ever whitened (bleached) your teeth?
Yes
No
Have you felt uncomfortable or self-conscious about the appearance of your teeth?
Yes
No
Have you been disappointed with the appearance of previous dental work?
Yes
No
BITE AND JAW JOINT
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking or popping)
Yes
No
Do you/would you have any problems with chewing gum?
Yes
No
Do you/would you have any problems chewing bagels, baguettes or other hard food?
Yes
No
Have your teeth changed in the last 5 years, become shorter, thinner or worn?
Yes
No
Are your teeth crowding or developing spaces?
Yes
No
Do you have more than one bite and squeeze to make your teeth fit together?
Yes
No
Do you chew ice, bite your nails, use your teeth to hold objects or have any other oral habits?
Yes
No
Do you clench your teeth in the daytime or make them sore?
Yes
No
Do you have any problems with sleep or wake up with an awareness of your teeth?
Yes
No
Do you wear or have you ever worn a bite appliance?
Yes
No
Have you ever experienced gum recession?
Yes
No
Have you ever had any teeth become loose on their own?
Yes
No
Have you experienced a burning sensation in your mouth?
Yes
No
TOOTH STRUCTURE
Have you had any cavities within the past 3 years?
Yes
No
Does the amount of saliva in your mouth seem low or do you have difficulty swallowing food?
Yes
No
Do you feel or notice any holes (pitting or craters) on the biting surface of your teeth?
Yes
No
Are any teeth sensitive to hot, cold, sweets or do you avoid brushing any part of your mouth?
Yes
No
Do you have grooves or notches on your teeth near the gum line?
Yes
No
Have you ever broken teeth, chipped teeth, had a toothache or cracked filling?
Yes
No
Do you get food caught between any teeth?
Yes
No
GUM AND BONE
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
Yes
No
Do your gums bleed when brushing or flossing?
Yes
No
Have you ever noticed an unpleasant taste or odor in your mouth?
Yes
No
Is there anyone with a history of periodontal disease in your family?
Yes
No
PATIENT SIGNATURE *
*
DATE *
*
Date Format: MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.