Dental History

Patient First name *
Patient Last Name *
Why you are changing dentist?
Change of residence Change of dental plan Your office is closer My dentist retired/closed Unhappy Too expensive You were recommended Other
Please explain
How long since the last visit to dentist? *
1 month 3 months 6 months 1 year 2 years 3 or more years I've never seen a dentist
Reason for the visit *
Check-up Cleaning Pain Other
Please provide details
Have you ever had a bad experience at the dentist *
No Yes
If yes please explain
Have you had any complications following dental treatment? *
No Yes
If yes please explain
Have you had unfavorable reaction to dental anesthetic? *
No Yes
If yes please explain
Does dental treatment make you nervous? *
No Yes, Slightly Yes, Moderately Yes, Extremely
Are your teeth sensitive to cold, hot? *
No Yes
Do your gums bleed when you brush or floss? *
No Yes
Do you grind your teeth? *
No Yes
Are you aware of sores or irritated areas in the mouth? *
No Yes
Have you ever been treated for Periodontal Disease? *
No Yes
How often do you brush? *
Once a day Twice a day Three times a day Every time I eat
How often do you floss? *
Never Occasionally Once a day Twice a day Three times a day Every time I eat
Do you like your smile? *
No Yes
If you could change your smile, what would you like to change?
The color of my teeth Close spaces or restore worn and broken teeth The shape of my teeth The position or alignment of my teeth Other
If Other please specify
I am interested in *
Teeth whitening Cosmetic evaluation Replacement of missing teeth Straight teeth Sedation White fillings Home care Breath control Other
If Other please specify
To ensure your visit is a great experience, please share any questions or concerns you would like us to know about