Dental History Form - Rda
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1
2RDA
ROESER
Patient Name:
DENTAL
ASSOCIATES, P.C.
Date:
Date of Birth:
Dental History
Y
N
Are you in good dental health? If not, explain:
Do you have any present dental complaints? If so, what?
Have you ever had a problem following a dental procedure? If so, what?
Have you ever been instructed in the prevention of tooth decay?
Have you ever been instructed in caring for your teeth and gums?
Do you have Fluoride in your drinking water?
Do you use Fluoride toothpaste?
Do you have a family history of decayed, missing or filled teeth? If yes, explain:
Do you have a family history of congenitally missing permanent teeth? If yes, explain:
Do you have a dry mouth or condition that impairs saliva?
Time lapse since last cavity?
<12 months
12-24 months
>24 months
Frequency of routine dental visits?
Every 6 months
Irregular
None
When was your last dental visit?
Daily between meal exposures to sugars/cavity
producing foods (includes on demand use of liquids
other than water or use of sweetened medications)?
>3
1-2
Mealtime Only
Times per day teeth/gums are brushed?
2-3
1
None
Times per day teeth/gums are flossed?
>1
1
None
Socioeconomic status:
Low
Mid-level
High
On a scale of 1 to 10 how frightened are you of dental treatment (10 is very frightened)?
Do you have or have you ever had:
Conditions
Y
N
Tooth Decay
Gum Disease
Braces or Orthodontics
Root Canals
Tooth Extractions
Jaw Pain
Temporomandibular Disorder
Complete or Partial Dentures
Tooth Aches
Sensitive Teeth
Dental Implants
Bridges
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Parent category: Medical