Dental Health History Form
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1Dental Health History Form
Today’s Date
Patient Name: First
MI
Last
Nickname
What are your goals in coming to our practice today?
What is important to you in a dentist or dental practice?
What has been your experience with the dentist in the past?
Date of last radiographs (x-rays) and exam
Date of last hygiene continuing care appointment
(cleaning or periodontal maintenance)
Former Dentist
Phone
Address: Street
City
State
Zip
If you left your previous dentist, what are the reasons?
Have you had problems with prior dental treatment?
Are you experiencing any pain now? Yes No
If yes, please describe
Have you ever been pre-medicated for dental treatment? Yes No
If yes, why?
Have you been anxious about having dental treatment? Yes No
If yes, would you be comfortable sharing why?
Would you like to discuss this concern with the doctor to learn about your relaxation options?
What concerns do you currently have with your oral health or smile?
(check all that apply)
Jaw joint pain
Unhappy with appearance of teeth
Tooth sensitivity to hot/cold or anything else
Clenching or grinding of teeth
Overbite
Food gets caught in between teeth
If yes, where
Discolored teeth
Underbite
Crowding/Crooked teeth
Uncomfortable bite
Difficulty chewing
If yes, where
Missing teeth
Old fillings
(gold or silver)
Spaces in between teeth
Old crowns
Bad breath
Loose tooth/teeth
Speech problems
Other
Tooth shape or size
Too much gum tissue when I smile
Have you ever had orthodontic treatment? Yes No
If yes, when?
Have you ever had periodontal (gum tissue) treatment, such as deep cleanings, root planing, or periodontal surgery? Yes No
If yes, when?
Have you whitened your teeth in the past? Yes No
If yes, what method?
Are you interested in learning more about the following?
(check all that apply)
Teeth Whitening
Tooth-colored fillings
At-home oral hygiene care
Orthodontic treatment
Dental implants
Periodontal treatment during pregnancy
Veneers
How to prevent periodontal disease
Oral hygiene care for infants and toddlers
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