"Dental Health History Form"

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Dental Health History Form
Today’s Date 
Patient Name: First 
  MI 
  Last 
  Nickname 
What are your goals in coming to our practice today? 
What is important to you in a dentist or dental practice? 
What has been your experience with the dentist in the past? 
Date of last radiographs (x-rays) and exam 
Date of last hygiene continuing care appointment 
(cleaning or periodontal maintenance)
Former Dentist 
  Phone 
  
Address: Street 
  City 
  State 
  Zip 
If you left your previous dentist, what are the reasons? 
Have you had problems with prior dental treatment? 
Are you experiencing any pain now?    Yes    No
If yes, please describe 
Have you ever been pre-medicated for dental treatment?    Yes    No
If yes, why? 
Have you been anxious about having dental treatment?    Yes    No
If yes, would you be comfortable sharing why? 
Would you like to discuss this concern with the doctor to learn about your relaxation options? 
What concerns do you currently have with your oral health or smile? 
(check all that apply)
Jaw joint pain
Unhappy with appearance of teeth
Tooth sensitivity to hot/cold or anything else
Clenching or grinding of teeth
Overbite
Food gets caught in between teeth 
If yes, where  
Discolored teeth
Underbite
Crowding/Crooked teeth
Uncomfortable bite
Difficulty chewing 
If yes, where  
Missing teeth
Old fillings 
(gold or silver)
Spaces in between teeth
Old crowns
Bad breath
Loose tooth/teeth
Speech problems
Other 
Tooth shape or size
Too much gum tissue when I smile
Have you ever had orthodontic treatment?    Yes    No
If yes, when? 
Have you ever had periodontal (gum tissue) treatment, such as deep cleanings, root planing, or periodontal surgery?    Yes    No
If yes, when? 
Have you whitened your teeth in the past?    Yes    No
If yes, what method? 
Are you interested in learning more about the following? 
(check all that apply)
Teeth Whitening
Tooth-colored fillings
At-home oral hygiene care
Orthodontic treatment
Dental implants
Periodontal treatment during pregnancy
Veneers
How to prevent periodontal disease
Oral hygiene care for infants and toddlers
Dental Health History Form
Today’s Date 
Patient Name: First 
  MI 
  Last 
  Nickname 
What are your goals in coming to our practice today? 
What is important to you in a dentist or dental practice? 
What has been your experience with the dentist in the past? 
Date of last radiographs (x-rays) and exam 
Date of last hygiene continuing care appointment 
(cleaning or periodontal maintenance)
Former Dentist 
  Phone 
  
Address: Street 
  City 
  State 
  Zip 
If you left your previous dentist, what are the reasons? 
Have you had problems with prior dental treatment? 
Are you experiencing any pain now?    Yes    No
If yes, please describe 
Have you ever been pre-medicated for dental treatment?    Yes    No
If yes, why? 
Have you been anxious about having dental treatment?    Yes    No
If yes, would you be comfortable sharing why? 
Would you like to discuss this concern with the doctor to learn about your relaxation options? 
What concerns do you currently have with your oral health or smile? 
(check all that apply)
Jaw joint pain
Unhappy with appearance of teeth
Tooth sensitivity to hot/cold or anything else
Clenching or grinding of teeth
Overbite
Food gets caught in between teeth 
If yes, where  
Discolored teeth
Underbite
Crowding/Crooked teeth
Uncomfortable bite
Difficulty chewing 
If yes, where  
Missing teeth
Old fillings 
(gold or silver)
Spaces in between teeth
Old crowns
Bad breath
Loose tooth/teeth
Speech problems
Other 
Tooth shape or size
Too much gum tissue when I smile
Have you ever had orthodontic treatment?    Yes    No
If yes, when? 
Have you ever had periodontal (gum tissue) treatment, such as deep cleanings, root planing, or periodontal surgery?    Yes    No
If yes, when? 
Have you whitened your teeth in the past?    Yes    No
If yes, what method? 
Are you interested in learning more about the following? 
(check all that apply)
Teeth Whitening
Tooth-colored fillings
At-home oral hygiene care
Orthodontic treatment
Dental implants
Periodontal treatment during pregnancy
Veneers
How to prevent periodontal disease
Oral hygiene care for infants and toddlers