Adult Medical-Dental History Page 5
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5Adult Medical-Dental History
Adult Dental History
Previous Dentist Name
Phone Number
Address
Purpose of initial visit
Are you aware of any problems?
Date of last dental visit?
When was your last cleaning?
Were x-rays taken?
Yes
No
Do your gums bleed or hurt?
Yes
No
How often do you brush?
How often do you floss?
History of gum surgery?
Yes
No
If yes, when?
Removed or lost any teeth?
Yes
No
If yes, why?
Any complications or problems with previous dental treatment?
Yes
No
If yes, explain:
Do you have any questions or concerns to talk to the doctor about?
Yes
No
Do you clench or grind your teeth?
Yes
No
Any soreness or pain in your jaw?
Yes
No
Does your jaw lock or pop?
Yes
No
Do you have frequent headaches?
Yes
No
Do you have any sensitive teeth?
Yes
No
Does food get caught in your teeth?
Yes
No
Are you happy with the appearance of your smile?
Yes
No
Have you had any orthodontic work?
Yes
No
Patient Signature
X
Signer's Full Name
Date
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