Download dental history - Dentist | Jackson, MO

DENTAL HISTORY
It is important to tell all dental personnel involved in your treatment about the general state of
your health. This information is confidential.
Name__________________________________________Date of Birth ____________________
1. Former Dentist __________________________Phone ______________________________
2. When did you last visit a dentist? _____________________X-rays taken? Yes ____ No _____
3.What was done at that time?____________________ ________________________________
4.How would you rate your smile? (Worst) 1 2 3 4 5 6 7 8 9 10 (Best)
5. Have you lost or have had any teeth removed, including wisdom teeth? Yes ______ No______
6. Do you have any bridge work or dentures? _________________________________________
7. Are you unhappy with the replacement? Yes ____ No ____ Why ________________________
8. Have you ever been told you have gum disease?
Yes ____ No ____
9. Have you ever had gum treatment or Surgery?
Yes ____ No ____
10. Does food chronically collect between your teeth?
Yes ____ No ____
11 Are your teeth acutely sensitive to: Sweet o Cold o Heat o Pressure o No o
12. How often do you brush your teeth? _____________________________________________
13. How often do you floss your teeth? ______________________________________________
14Reason for today’s visit? ()Exam ()Emergency ()Consultation
15.Are you in pain? ()Yes ()No How long? _________
16.Please indicate any of the following problems:
()Discomfort, clicking or popping in jaw. ()Lost / Broken Filling(s)
()Stained teeth
()Bad Breath
()Red swollen or bleeding gums.
()Locking jaw
()Ringing in ears
()Sensitive tooth, teeth or gums
()Blisters-Sores in or around the mouth
()Broken / Chipped tooth
()Teeth grinding
()Other____________________________________________
17. Do you have frequent headaches?
Yes ____ No ____
18. Have you had any orthodontic work?
Yes ____ No ____
I certify that the above information is complete and accurate.
Patient's/Guardian's Signature_____________________________ Date____________________