Patient Dental History Form

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PATIENT DENTAL HISTORY
Patient’s name________________________________________________ Date of Birth__________________________
Reason for this visit_________________________________________________________________________________
Last dental visit (date) __________________ Treatment provided at that time___________________________________
Frequency of dental visits___________ Previous dentist (name and location) ___________________________________
Have you had a complete series of dental films/x-rays taken? ________ Where?_________________________________
When? _____________________________ Can we request these be sent to this office?__________________________
Please indicate Yes (Y) or No (N) to the following:
Do your gums bleed while brushing or flossing? ____
Do you bite your lips/cheeks frequently?
____
Are your teeth sensitive to hot or cold?
____
Have you notices any loosening of your teeth?
____
Does food get caught between your teeth?
____
Are your teeth sensitive to sweets or sour?
____
Have you had periodontal (gum) treatment?
____
Do you feel pain in any of your teeth?
____
Have you received oral hygiene instruction for
Do you have any sores or lumps in or near
the care of your teeth and gums?
____
your mouth?
____
Have you difficult extractions before?
____
Have you ever had any head, neck or jaw
injuries?
____
Have you had prolonged bleeding following
extractions before?
____
Have you ever experienced any of the
following problems in your jaw?
Do you wear dentures or partials?
____
Clicking
____
If yes, date of placement______________________
Pain (joint, ear or side of face)
____
Do you have dental implants?
____
Difficulty in opening/closing
____
If yes, date of placement______________________
Difficulty in chewing
____
Have you had orthodontic treatment?
____
Do you have frequent headaches?
____
If yes, date of completing__ ____________________
Do you clench or grind your teeth?
____
Have you had treatment from a dental specialist? ____
If yes, what type?______________________________
Additional comments or concerns? ____________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Dentist’s comments_________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________
_______________
_________________________
_________________
Patient’s/Parent’s/Guardian’s signature
Date
Dentist’s signature
Date

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