Dental History Name* Previous Dentist How long? Last dental exam Last dental treatment How often do you have your teeth cleaned? 3 months 4 months 6 months 1 yr or longer How would you rate your past care? What is your immediate dental concern? Please check if you have, or ever had the following: Unhappy with appearance of your teeth Unfavorable dental experiences Dental fears Preference for no dental anesthetic Problems with effectiveness or bad reactions to dental anesthetic Orthodontic treatment (braces) Periodontal (gum) treatment Bleeding gums Loose teeth Avoid brushing any part of your mouth Part of your mouth is sensitive to temperature or sweets Sore teeth A burning sensation in your mouth Difficulty swallowing An unpleasant taste or odor in your mouth. Jaw problems (temporomandibular joint) Difficulty opening your mouth widely Stiff neck muscles Awaken with an awareness of your teeth or jaw Lost any teeth History of trauma to teeth or jaw When did you receive orthodontic treatment? Supplemental Denture HistoryAre you are wearing a partial or complete artificial denture? Yes No Has your present denture been relined? Yes No When? Is your present denture a problem? Yes No Describe Satisfied with the appearance? Yes No Satisfied with the comfort? Yes No Satisfied with the chewing ability? Yes No When did you receive your first partial or complete denture? How long have you worn your present denture? I agree to allow the release of any records deemed necessary, including periodontal charting and x-rays, to my representative insurance company or companies.Patient's Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY
