Download Patient Dental History Form

GEORGE GOTSIRIDZE, D.M.D., LLC
LAWRENCE I. A. ROTHENBERG, D.D.S., M.S., P.C.
THE BARLOW BUILDING, SUITE 1350
5454 WISCONSIN AVENUE
CHEVY CHASE, MARYLAND 20815
TEL: (301)652-1545
FAX: (301)652-4171
PATIENT DENTAL HISTORY
Our office is like no other dental office. Your first visit will be one of the most important dental visits you will ever have since
we place a strong emphasis on helping you determine your present and future dental needs. Here are some of the things we are
going to be discussing with you, some of which you may never consider.
Are you having any areas of concern?_______________________________________________________________________
Tell us what you think of the present state of health of your mouth?_______________________________________________
Tell us about your good dental experience…__________________________________________________________________
And the bad ones…_____________________________________________________________________________________
What caused you to leave your last dental office?______________________________________________________________
On a scale of 1 to 10, how would you rate your smile?__________________________________________________________
What would you like to change about your smile?______________________________________________________________
Referred by?___________________________________________________________________________________________
Do you have or have you ever had any of the following?
□ Gums that bleed, are tender, swollen
or irritated
□ Sensitive teeth (heat, cold, sweets, pressure)
□ Food wedging between teeth
□ Artificial replacement for missing teeth
□ Grinding or clenching of teeth
□ Burning of tongue and mouth
□ Endodontic therapy (root canal)
□ Offensive breath
□ Bad taste
□ Periodontal therapy (gum treatment)
□ Injury to jaw or mouth
□ Swellings, lumps, or
white patches in your mouth
□ Popping, clicking or snapping noises
□ Nasal Obstruction
□ Ulcers or fever blisters
□ Allergy to local anesthesia
□ Orthodontic therapy
□ Frequent headaches or neck aches
□ Extractions
□ Professional home care
□ Equilibration (grinding. Bruxing)
□Recent weight loss or gain in excess of 10 lbs
Would you like to have whiter teeth? □ Straighter teeth? □ ___________________________________________________________
Has fear ever been an issue for you in the dental office?______________________________________________________________
Is there any additional information you would like us to know?________________________________________________________