Dental History
Dental History:
Patient:
Yes No Question
1. How would you rate the condition of your oral health? Excellent, good, fair or poor
2. Date of your most recent dental exam? Month and Year
3. Date of your most recent radiographs (x-rays)? Month and Year
4. I routinely see my dentist every 3/6/9/12 months/ not routinely.
5. What is your immediate concern?
6. Have you ever had complications from past dental treatment?
7. Have you ever had trouble getting numb or had any reactions to local anesthetic?
8. Are you allergic to any dental materials such as latex?
Are you experiencing any of the following?
1. Teeth Chipping or wearing
2. Food getting caught between teeth
3. Difficulty flossing
4. Biting lips, cheek or tongue
5. Bad breath
6. Dry mouth or mouth breathing
7. Jaw or muscle pain or headaches
8. Receding gums or indentations at the gum line
9. Cold sensitivity
Signature: Date: