Confidential Dental And Medical History Page 3
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7Dental History
Answers to these questions help us provide safe and effective dental care personalized to your individual needs.
YES NO
ARE ANY OF YOUR TEETH SENSITIVE TO:
Hot or cold? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Sweets? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Biting or chewing? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Have you noticed any mouth odors or bad taste?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Do you frequently get cold sores? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Do you frequently get oral ulcers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Do your gums bleed or hurt? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Have you noticed any loose teeth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Have your teeth shifted over the years?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Does food tend to become caught in between your teeth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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DO YOU:
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Clench or grind your teeth while awake or asleep? Have tired jaws, especially in the morning? . . . . . . . . . . . . . . . . .
Have a hard time opening wide? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Mouth breathe while awake or asleep? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Hold foreign objects with your teeth (i.e. pencils, nails)? Chew ice often?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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HAVE YOU EXPERIENCED ANY OF THE FOLLOWING:
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Clicking or popping of the jaw? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pain in the jaw joint area near the ear?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Difficulty in opening or closing your mouth? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Headaches, neck aches, or shoulder aches frequently?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Sore muscles in the neck or shoulders? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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I WOULD LIKE TO LEARN MORE ABOUT:
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Orthodontics
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Cosmetic Dentistry
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Sedation Dentistry
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Implants
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Whitening
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Bridges
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Veneers
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Dentures
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Other _______________________________________________
When was your last dental visit? _________________________________________________________________________________
What was completed during your last dental visit? __________________________________________________________________
Last dental x-rays?_________________ How often do you have dental examinations ? _____________________________________
How often do you brush your teeth? ____________________________ How often do you floss? _____________________________
What other dental aids do you use? (electric brushes, toothpick, etc.) ___________________________________________________
Do you have any dental problems that you are aware of now? If yes, please describe. ______________________________________
____________________________________________________________________________________________________________
Do you feel nervous about dental treatment? If yes, what is your biggest concern? _______________________________________
_________________________________________________________________________________
T Y P E N A M E
D AT E
904.262.8409
Bartram Office
Riverside Office
}
13241 Bartram Park Blvd.
501 Riverside Ave.,
Bldg. 1700
Suite 104
Jacksonville, FL 32258
Jacksonville, FL 32202
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Parent category: Medical