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.): ____________________________ __________________________________________________________________________________________________ 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 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 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 8. TMD Evaluation Difficulty swallowing effectively Bleeding gums Gingival gum pain or swelling Frequent cold or mouth sores White patches in the mouth Dry mouth problems Toothaches Sensitive teeth Pain upon biting and/or chewing Loose or moving teeth Teeth break or fracture easily Food catching between your teeth None Toothaches Sensitive teeth Pain upon biting and/or chewing Loose or moving teeth Teeth break or fracture easily Food catching between your teeth None Toothaches Sensitive teeth Pain upon biting and/or chewing Loose or moving teeth Teeth break or fracture easily Food catching between your teeth Orthodontics or Braces Date:________ Bite (occlusion) treatment Jaw joint Treatment Root canal Treatment Dentures Injury to teeth or face Crown, bridge, Implant None Yes No

 Bad breath

None