Dental History

How do you feel about dental treatment?

RelaxedA little uneasyTenseAnxiousVery Anxious

How often do you use other aids?
Less than once per weekOnce per weekSeveral times per weekOnce per dayTwice per dayThree times per day

water flosser, gum picks, gum stimulator, etc.

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

Aching or sensitive teethAreas of food trapsBroken fillingCavitiesCold soresDry mouthFacial surgeryGrowths or lesions in your mouthGum treatmentsJaw clenchingNight guardOrthodontic treatmentSwelling or lumps in mouthTeeth grindingNone of the aboveActive decay of teeth or gumsBad breathBroken or missing teethClicking or popping jawDifficulty opening wideAesthetic concerns with teethGag easilyGum infection / diseaseJaw pain or tirednessLoose teethOral surgerySensitive or bleeding gumsSwollen glandsUnfavorable dental experience

Previous dentist or dental office

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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