Dental History

CHIEF COMPLAINT:

1. Do you want to change the appearance of your teeth?

Yes

No

If yes, explain: ____________________________________________________________

2. Would it upset you to lose your teeth and wear dentures?

Yes

No

If yes, explain: ____________________________________________________________

3. Do you have a private dentist? (If referred, name of dentist): ___________________________

Comments: (Last time seen, how often, care received, etc.): ___________________________ Yes No

4. Has your dental history changed since your last recall &/or appointment? 5. PREVIOUS DENTAL TREATMENTS (CHECK ALL THAT APPLY) :
Regular Preventive Care Date of last prophy: ______ Periodontal (gum) Treatment Extractions Other oral surgery treatment Ortho/Braces Date:________ Bite (occlusion) treatment Jaw joint Treatment Root canal Treatment

Dentures Injury to teeth or face Crown, bridge, Implant None

6. CURRENT PROBLEMS & CONCERNS:

Difficulty swallowing effectively Bleeding gums Gingival gum pain or swelling Frequent cold or mouth sores White patches in the mouth Dry mouth problems Bad breath Toothaches Sensitive teeth Pain upon biting and/or chewing Loose or moving teeth Teeth break or fracture easily Food catching between your teeth None

7. ORAL HABITS AND PREVENTIVE PRACTICES:

Difficulty swallowing effectively Bleeding gums Gingival gum pain or swelling Frequent cold or mouth sores White patches in the mouth Dry mouth problems Bad breath Toothaches Sensitive teeth Pain upon biting and/or chewing Loose or moving teeth Teeth break or fracture easily Food catching between your teeth None

8. TMD Evaluation
Difficulty swallowing effectively Bleeding gums Gingival gum pain or swelling Frequent cold or mouth sores White patches in the mouth Toothaches Sensitive teeth Pain upon biting and/or chewing Loose or moving teeth Teeth break or fracture easily

 Dry mouth problems Bad breath

Food catching between your teeth None