Dental History
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