Dental History Form

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DENTAL HISTORY
Comments
1.
Purpose of initial visit
__________________________________________
2.
How long since your last dental visit?
__________________________________________
3.
What was done at that time?
__________________________________________
4.
Previous Dentist’s name
__________________________________________
5.
When was the last time your teeth were cleaned?
__________________________________________
CIRCLE THE APPROPRIATE ANSWER. IF YOU DON’T KNOW
THE CORRECT ANSWER, PLEASE WRITE “DON’T KNOW”
IN THE COMMENTS SECTION.
6. Are you aware of a problem?
YES NO
7. Have you made regular visits to a dental office?
YES NO
8. Were dental x-rays taken?
YES NO
9. Are you missing any teeth?
YES NO
10. Would you like to know about permanent
replacements?
YES NO
11. Have you ever had any problems or complications with
previous dental treatment?
If yes, explain:
YES NO
_____________________________________________
12. Do you clench or grind your teeth?
YES NO
13. Does your jaw click or pop?
YES NO
14. Have you experienced any pain or soreness in the
muscles around your face or ears?
YES NO
15. Do you have frequent headaches, neck aches or
YES NO
shoulder aches?
16. Does food get caught in your teeth?
YES NO
17. Are any of your teeth sensitive to HOT, COLD,
SWEETS or PRESSURE?
YES NO
18. Do your gums bleed or hurt?

YES NO
642 Shadows Lane
Phone: (225) 926-1059
Baton Rouge, LA 70806
Email:
Fax: (225) 924-6570

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