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DentistPatient/GuardianDate of last cleaning and examHow would you rate the condition of your mouth?How often do you see the dentist?Date of most recent treatment (other than a cleaning)
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Any teeth sensitive to sweet, hot, cold, or biting?Do you chew ice, bite your nails?Problems with sleep?Felt uncomfortable or self conscious about the appearance of your teeth?Family history of gum disease?Do you wear or ever worn a bite appliance?Have you ever been disappointed with the appearance of previous dental work?BITE AND JAW JOINTAre you fearful of dental treatment?Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?Clench or grind your teeth in the daytime?GUM AND BONEPERSONAL HISTORYNYNCavities in the past 3 years?Please answer yes or no to the following:YLast Name:First Name:Birthdate:Frequently get food caught between any teeth?Loose teeth?Have you ever whitened your teeth?Difficulty swallowing any food because of dry mouth?Burning or painful sensation in your mouth?TOOTH STRUCTURETrouble finding your bite? Bite not balance?Ever had broken teeth, chipped teeth or cracked filling?Wake up with headaches or awareness of your teeth?Experience gum recession?Date: 2/27/2024SMILE CHARACTERISTICSGrooves or notch on your teeth near the gum line?Unpleasant taste or odor in your mouth?Feel or notice any holes on the biting surface of teeth?Avoid brushing on one side?Tobacco use? If so, what kind and how much?Been told you had gum disease?Teeth more crooked, crowded, or overlapped?Teeth spacing or becoming more loose?Bleeding gums or pain when flossing/brushing?Do you use vaping products?Immediate Concern?City/StateHow long have you been a patient of your previous dentist?Unusual reaction to dental injections?Name of former dentistDo you have BiteWing x-rays that are less than 1 year old?Are you in pain?Do you have a Panoramic x-ray or Full Mouth x-rays that are less than 5 years old?Avoid/difficulty chewing hard food?Problems with jaw joints? (pain, locking, popping)Complications from past dental experience?Lower jaw being push back when biting?Have you had an unfavorable experience?Lost teeth due to injury or facial trauma?Have you ever had trouble getting numb?Teeth become shorter, thinner, worn?Orthodontic treatment?In the past 5 yrs, has your bite changed?Dental History for New Patient