Fillable Patient Dental History printable pdf download

PATIENT DENTAL HISTORY

PATIENT’S NAME _______________________________________________________________

DATE OF BIRTH __________________________________

REASON FOR THIS VISIT _____________________________________________________________________________________________________________

WHEN WAS YOUR LAST DENTAL VISIT __________________________WHAT WAS DONE THEN _________________________________________________

HOW OFTEN DID YOU VISIT THE DENTIST BEFORE THEN ________________________________________________________________________________

PREVIOUS DENTIST (NAME AND LOCATION) ____________________________________________________________________________________________

HAVE YOU HAD A COMPLETE SERIES OF DENTAL FILMS (X-RAYS) TAKEN- WHEN & WHERE __________________________________________________

HOW OFTEN DO YOU BRUSH YOUR TEETH ___________________________ HOW OFTEN DO YOU FLOSS YOUR TEETH __________________________

IS YOUR DRINKING WATER FLUORIDATED

YES

YES NO

Do your gums bleed while brushing or flossing………..……

Do you bite your lips or cheeks frequently……………...……

Are your teeth sensitive to hot or cold liquids/foods……..…

Have you noticed any loosening of your teeth………….…..

Are your teeth sensitive to sweet or sour liquids/foods…….

Does food tend to become caught between

your teeth……………………………………………………….

Do any of your teeth feel painful.......……………………..….

Have you ever had periodontal treatment (gums)………….

Do you have any sores or lumps in or near your mouth…....

Have you ever worn a bite plate or other appliance………...

Have you had any head, neck, or jaw injuries………………

Have you had any difficult extractions in the past………..…

Have you experienced any of the following problems

Clicking in your jaw...………………………………

Have you ever had any prolonged bleeding following

Pain (joint, ear, side of face)………………………

Extractions…………………………………………….………..

Difficulty in opening or closing your jaw………….

Do you wear dentures or partials………………….……….…

Difficulty in chewing…………………………………

If yes, give the date they were placed

______________________________________

Do you have frequent headaches………………………….…

Have you ever received oral hygiene instructions

Do you clench or grind your teeth………………………….…

regarding the care of your teeth and gums………………..…

IF YOU COULD CHANGE ANYTHING ABOUT YOUR SMILE, WHAT WOULD YOU CHANGE?

AUTHORIZATION AND RELEASE

I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION TO THE BEST OF MY KNOWLEDGE. THE ABOVE QUESTIONS HAVE BEEN ACCURATELY

ANSWERED. I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH. I AUTHORIZE THE DENTIST TO RELEASE ANY

INFORMATION INCLUDING THE DIAGNOSIS AND THE RECORDS OF ANY TREATMENT OR EXAMINATION RENDERED TO ME OR MY CHILD DURING THE PERIOD OF SUCH

DENTAL CARE TO THIRD PARTY PAYORS AND/OR HEALTH PRACTITIONERS. I AUTHORIZE AND REQUEST MY INSURANCE COMPANY TO PAY DIRECTLY TO THE

DENTIST OR DENTAL GROUP INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I UNDERSTAND THAT MY DENTAL INSURANCE CARRIER MAY PAY LESS THAN THE

ACTUAL BILL FOR SERVICES. I AGREE TO BE RESPONSIBLE FOR PAYMENT OF ALL SERVICES RENDERED ON MY BEHALF OR MY DEPENDENTS.

________________________________________________________________________________

___________________________________________

SIGNATURE OF PATIENT OR PARENT/GUARDIAN IF MINOR

DATE

________________________________________________________________________________

___________________________________________

DOCTOR’S SIGNATURE

DATE

DOCTOR’S COMMENTS ___________________________________________________________________________________________________

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Patient Dental History

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