DENTAL HISTORY PATIENT’S NAME DATE 1 IF YOU ARE

Dental History

Dental History

Patient’s Name Date

1. If you are a new patient to our practice please provide the following information about your previous dentist so that,

if required, we may consult with them in order to provide you with the best possible care.

Name Address

City/State/ZIP Phone number

2. When did you last visit a dentist and for what purpose?

3. Did you make regular visits to the dentist before then? Yes No

4. Has any Doctor ever told you that you must receive antibiotic

premedication before having any dental treatment performed? Yes No

If yes, list Doctor and reason.

What medication was prescribed?

5. Are you aware of any dental problems at this time? Yes No

If yes, please list.

6. What do you feel is the present condition of your mouth?

7. Do your gums bleed when you brush or floss? Yes No

8. Have you ever been told you have gum disease? Yes No

9. Have you ever had gum surgery? Yes No

10. Does food collect between your teeth? Yes No

11. Are your teeth sensitive to: (circle those that apply) sweet cold heat pressure

12. Are you missing any teeth (other than wisdom teeth)? Yes No

13. Do you wear a removable partial(s) or denture(s)? (Circle) Yes No

Are you satisfied with the fit of your partial(s) or denture(s)? Yes No

How old is/are your partial(s) or denture(s)?

14. Are you satisfied with the function of your teeth? Yes No

If no, what is your concern?

16. Are you pleased with the appearance of your teeth? Yes No

If no, what is your concern?

17. Is there anything about receiving dental treatment that concerns you? Yes No

If yes, please explain.

18. Do you feel nervous or apprehensive about having dental treatment performed? Yes No

If yes, would an oral sedative make your dental appointment more comfortable? Yes No Unsure

If yes, would Nitrous Oxide (gas) make your dental appointment more comfortable? Yes No Unsure