Adult Dental History Form

Patient Name:

Patient Email:

Date of Birth:

Patient Phone:

How would you rate the condition of your mouth?

Excellent
Good
Fair
Poor

How frequently do you get your teeth cleaned?

Previous dentist:

How long have you been a patient?

Date of most recent dental exam:

Date of most recent x-rays:

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 **

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Phone

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