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425-614-1600

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1299 156th Ave NE Ste 115,
Bellevue, WA 98007

2

Locations

901 Boren Ave suite 1733
Seattle WA 98104

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Dental History

How do you feel about dental treatment?

Relaxed
A little uneasy
Tense
Anxious
Very Anxious

Have you seen a dentist before?

Yes
No

YesNo If so, when was your last dental visit?

How would you rate your previous dental experience?

What are your dental concerns?

Have you avoided regular dental care?

Yes
No

If so, why have you avoided regular dental care?

Are you happy with the appearance of your teeth?

Yes
No

If not, why are you unhappy with the appearance of your teeth?

How often do you brush?

How often do you floss?

How often do you use other aids?

water flosser, gum picks, gum stimulator, etc.

Would you like your teeth to be whiter?

Yes
No

Would you like your teeth to be straighter?

Yes
No

Do you have, or have you ever had any of the following dental conditions? Please check all that apply. *

Aching or sensitive teeth
Areas of food traps
Broken filling
Cavities
Cold sores
Dry mouth
Facial surgery
Growths or lesions in your mouth
Gum treatments
Jaw clenching
Night guard
Orthodontic treatment
Swelling or lumps in mouth
Teeth grinding
None of the above
Active decay of teeth or gums
Bad breath
Broken or missing teeth
Clicking or popping jaw
Difficulty opening wide
Aesthetic concerns with teeth
Gag easily
Gum infection / disease
Jaw pain or tiredness
Loose teeth
Oral surgery
Sensitive or bleeding gums
Swollen glands
Unfavorable dental experience

Previous dentist or dental office

Name of previous dentist or dental office

State / Province

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in status.

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Contact Info

1299 156th Ave NE Ste 115, Bellevue, WA 98007
(425) 614-1600
info@bellevuefamilydentist.com

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