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| DENTAL HISTORY | |||||||||||
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| DO YOU HAVE or HAVE YOU EVER HAD (check all that apply): |
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1.
Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)
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2.
Have you had an unfavorable dental experience?………………………………………………………………...…………………………………………………………………………………………………………………………………………………………
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3.
Have you ever had complications from past dental treatment? …………....……………………………………………………………………………………………………………………………………………………………
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4.
Have you ever had trouble getting numb or had any reactions to local anesthetic? ……………………………………………………………………………………………………………………………………………………
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5.
Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
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6.
Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?…………………..…………………………………………………………………………
Have you had any teeth removed, missing teeth that never developed or
lost teeth due to injury or facial trauma?…………………..…………………………………………………………………………………………… |
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7.
Do your gums bleed sometimes or are they ever painful when brushing or flossing?………….…………………………………………………………………………………………………………………………………
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8.
Have you ever been treated for gum disease or been told you have lost bone around your teeth?………………………………………………………………..……………………………………………………………………………………
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9.
Have you ever noticed an unpleasant taste or odor in your mouth?………………………………………………………………………………………………………………………………………………………………………………
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10.
Is there anyone with a history of periodontal disease in your family?…………………………………………………….…………………………………………………………………………………………………………………
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11.
Have you ever experienced gum recession, or can you see more of the roots of your teeth?…………………………………………………………………………………………………………………………………
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12.
Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?……………………………………………………………………………………………
Have you ever had any teeth become loose on their own (without an injury),
or do you have difficulty eating an apple?…………………………………………………………………………………………………………………… |
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13.
Have you experienced a burning or painful sensation in your mouth not related to your teeth?………………………………………………………………………..……………………………………………………………………………
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14.
Have you had any cavities within the past 3 years?…………………………………………………………………………………………………………………………………………………………………………………………………………………………………
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15.
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?…………………………………………………………………………………………………………………
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16.
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?……………………………………………………………………………………………………………………………………
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17.
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?…………………………………………………………………………………………………………………
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18.
Do you have grooves or notches on your teeth near the gum line?.…………………………………………………………………………………………………………………………………………………………………………………
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19.
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?………..…………………………………………………………………………………………………………………………………………………
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20.
Do you frequently get food caught between any teeth?……………………………………………………………..…………………………………………………………………………………………………………………………
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21.
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)……………………………………………………………………………………………………………………………………
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22.
Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?……….………………………………………………………………………………………………………………
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23.
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?………………………………………………………………………………………………
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars,
or other hard, dry foods?……………………………………………………………………………………………………………………………… |
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24.
In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?………………………………………………………………………………………………………………
In the past 5 years, have your teeth changed (become shorter, thinner, or worn)
or has your bite changed?………………………………………………………………………………………………………………………………………………………………… |
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25.
Are your teeth becoming more crooked, crowded, or overlapped?………………………………………………………………………………………………………………………………………………………………………………
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26.
Are your teeth developing spaces or becoming more loose?………………………………………………………………………………………………………………………………………………………………………………………
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27.
Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?…………………………………………………………………………………
Do you have trouble finding your bite, or need to squeeze, tap your teeth together,
or shift your jaw to make your teeth fit together?…………………………………………………………………………………………………………………… |
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28.
Do you place your tongue between your teeth or close your teeth against your tongue?……………………………………………………………………………………………………………………………………………
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29.
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?…………………………………………………………………………………………………………………………………
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30.
Do you clench or grind your teeth together in the daytime or make them sore?…………………………………………………………………………………………………………………………………………………………
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31.
Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or awareness of your teeth?……………………………………………………………………………
Do you have any problems with sleep (i.e. restlessness or teeth grinding),
wake up with a headache or awareness of your teeth?…………………………………………………………………………………………………………………………………………… |
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32.
Do you wear or have you ever worn a bite appliance?…………………………………………………………………………………………………………………………………………………………………………………………………
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33.
Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (shape, color, size)?………………………………………………………………
Is there anything about the appearance of your mouth (smile, lips, teeth, gums)
that you would like to change (shape, color, size)?…………………………………………………………………………………………………………………………………………………… |
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34.
Have you ever whitened (bleached) your teeth?…………………………………………………………………………………………………………………………………………………………………………………………………………
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35.
Have you felt uncomfortable or self-conscious about the appearance of your teeth?…………………………………………………………………………………………………………………………………………………
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36.
Have you been disappointed with the appearance of previous dental work?………………………………………………………………………………………………………………………………………………………………
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I understand that all outstanding balances are due at the time services are rendered.
If payment is not received within 30 days, or if I designate prior, my credit card on file may be charged for any outstanding balances due.
Reservation Policy: Each appointment is a reservation with one of our Doctors or Hygienists and we strive to be punctual because we value our patients’ time. We ask for a minimum of 48 hours notice to cancel or reschedule any reservations and to avoid a Missed Reservation Fee. For appointments over 2 hours long or scheduled outside of our normal business hours, we request a 25% non-refundable deposit to secure your reservation.
| PLEASE RETURN THIS FORM WITH: |
1) A FORM OF GOVERNMENT-ISSUED ID 2) CREDIT CARD 3) INSURANCE CARD If you would like us to submit claims to your insurance, please provide your SSN: |
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PATIENT’S SIGNATURE