The information provided on this form is important to your dental health. Please complete all of questions to the best of your ability. If there have been any changes in your health, please tell us. Questions are welcome and appreciated.
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Patient First Name: *
Patient Middle Name:
Patient Last Name: *
Patient Email: *
Home phone: *
Work phone:
Cell phone:
Previous Dentist:
Date of last dental visit(if not here):
What problems have you had with past dental treatments?:
How do you feel about the appearance of your teeth?
Do your gums bleed when you brush?
Have you had any periodontal treatment?
Have you had facial or gum swelling?
Do you experience any clicking or popping in your jaw?
Are you aware that you clench or grind your teeth?
Do you have headaches?
Do you have a nightguard, splint, snore guard?
I often catch food between my teeth:
I would like fresher breath:
I have or have had jaw pain (TMJ):
I clench or grind my teeth:
I have problems eating
I have had orthodontics
I feel that my teeth have shifted:
I avoid brushing part of my mouth due to pain:
My mouth often feels dry:
I prefer tooth colored fillings:
I smoke or use tobacco:
Do you use a mechanical (electric) toothbrush?
If yes, which brand?:
Do you use flossing aids (holder, threaders, etc.):
Do you use an oral irrigation device (Waterpik)?:
Do you use flouride treatments of supplements at home?
If so, which brand?
Do you use mouthwashes or oral rinses?
Have you ever had any complications from an extraction or dental treatment?
If yes, please specify:
Have you been bothered by?
Tooth pain
Dry mouth
Uneven bite
Tooth color/appearance
Rough / sharp tooth surface
Bad breath
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