Dental Information Form
(STEP 3 OF 3 )
Answers to the following questions will allow your dentist to treat you on a more individual basis, providing the care appropriate to your particular needs. Your answers are for our records only and will be considered confidential.

Last Name: First Name:
Are you having any discomfort at this time? YES NO
Have you ever had any serious trouble associated with previous dentistry? YES NO
Does Dental treatment make you nervous?
Date of last dental visit (mmddyy):
Have you ever been treated for periodontal disease
(gum disease, pyorrhea, trench mouth)?		 YES NO
How often do you brush?
Brush is:

Do you have or have you ever had any problems with?

MOUTH TEETH
  • Bleeding, sore gums YES NO
  • Unpleasant taste/bad breath YES NO
  • Burning tongue/lips YES NO
  • Frequent blister, lips/mouth YES NO
  • Swelling/lumps in mouth YES NO
  • Ortho treatments (braces) YES NO
  • Biting cheeks/lips YES NO
  • Clicking/popping jaw YES NO
  • Difficulty opening or closing jaw YES NO
  • Loose Teeth YES NO
  • Sensitive to hot YES NO
  • Sensitive to cold YES NO
  • Sensitive to sweets YES NO
  • Sensitive to biting YES NO
  • Food impactation YES NO
  • Clenching/grinding YES NO
  • If so, when?
    Shifting in bite? YES NO
    Change in bite YES NO

Do you use the following?
  • Brush? YES NO
  • Fluoride rinse? YES NO
  • Dental floss? YES NO
  • Other?

These are the things that are important to me about my dental health:


Please select the answers that apply to you:
A:
B:
C:
D:
E:
F:
G: I think my present state of dental health is:

Do you have anyany questions about dentistry and oral health?


What do you expect from our office?