Name Nickname Age Referred by How would you rate the condition of your mouth? ExcellentGoodFairPoor Previous Dentist How long have you been a patient? (Months/Years) Date of most recent dental exam Date of most recent x-rays Date of most recent treatment (other than a cleaning) I routinely see my dentist every: 3 mo.4 mo.6 mo.12 mo.Not routinely WHAT IS YOUR IMMEDIATE CONCERN? PLEASE ANSWER YES OR NO TO THE FOLLOWING: PERSONAL HISTORY Are you fearful of dental treatment? YesNo Have you had an unfavorable dental experience? YesNo Have you ever had complications from past dental treatment? YesNo Have you ever had trouble getting numb or had any reactions to local anesthetic? YesNo Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age? YesNo Have you had any teeth removed or missing teeth that never developed or lost teeth due to injury or facial trauma? YesNo GUM AND BONE Do your gums bleed or are they painful when brushing or flossing? YesNo Have you ever been treated for gum disease or been told you have lost bone around your teeth? YesNo Have you ever noticed an unpleasant taste or odor in your mouth? YesNo Is there anyone with a history of periodontal disease in your family? YesNo Have you ever experienced gum recession? YesNo Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? YesNo Have you experienced a burning or painful sensation in your mouth not related to your teeth? YesNo TOOTH STRUCTURE Have you had any cavities within the past 3 years? YesNo Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? YesNo Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? YesNo Are any teeth sensitive to hot, cold, biting, sweets,or do you avoid brushing any part of your mouth? YesNo Do you have grooves or notches on your teeth near the gum line? YesNo Have you ever broken teeth,chipped teeth, or had a toothache or cracked filling? YesNo Do you frequently get food caught between any teeth? YesNo BITE AND JAW JOINT Do you have problems with your jaw joint? (pain, sounds, limited opening,locking, popping) YesNo Do you feel like your lower jaw is being pushed back when you bite your back teeth together? YesNo Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars,or other hard,dry foods? YesNo In the past 5 years, have your teeth changed (become shorter,thinner or worn) or has your bite changed? YesNo Are your teeth becoming more crooked,crowded,or overlapped? YesNo Are your teeth developing spaces or becoming more loose? YesNo Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together? YesNo Do you place your tongue between your teeth or close your teeth against your tongue? YesNo Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits YesNo Do you clench or grind your teeth together in the daytime or make them sore? YesNo Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth? YesNo Do you wear or have you ever worn a bite appliance? YesNo SMILE CHARACTERISTICS Is there anything about the appearance of your teeth that you would like to change (shape, color, size)? YesNo Have you ever whitened (bleached) your teeth? YesNo Have you felt uncomfortable or self conscious about the appearance of your teeth? YesNo Have you been disappointed with the appearance of previous dental work? YesNo Patient’s Signature Date Doctor’s Signature Date
