Name

First Last

Date

MM

DD

YYYY

The following information is for our records and will be kept confidential.

Are you having any dental pain now?*

Yes
No

When was your last dental visit?*

MM

DD

YYYY

What was done at that time?*

Do you floss?*

Yes
No

How often?*

How times a day do you brush?*

What type of toothbrush are you currently using?

Manual
Mechanical

Hot or Cold*

Yes
No

Sweets*

Yes
No

Biting or Chewing*

Yes
No

Toothpaste/Rinse*

Yes
No

Have you noticed any bad breath or bad tastes?*

Yes
No

Do you frequently get cold sores or any other oral lesions?*

Yes
No

Do your gums ever bleed or hurt?*

Yes
No

Have your parents lost any teeth or had gum disease?*

Yes
No

Do you have any family history of Diabetes?*

Yes
No

Do you smoke, or chew tobacco?*

Yes
No

Have you noticed any loose teeth, or a change in your bite?*

Yes
No

Does food tend to get caught between your teeth?*

Yes
No

Clench or grind your teeth while awake, or asleep?*

Yes
No

Breathe by your mouth while awake, or asleep?*

Yes
No

Have tired jaws, especially in the morning?*

Yes
No

Orthodontic treatment (Braces)?*

Yes
No

Oral surgery (Extractions)?*

Yes
No

Periodontal treatment (Gum Disease)?*

Yes
No

Your teeth ground, or bite adjusted?*

Yes
No

A bite plate, or mouth guard?*

Yes
No

A serious injury to your mouth, or head?*

Yes
No

Clicking or popping in your jaws?*

Yes
No

Headaches, neck or shoulder pain?*

Yes
No

What do you think about losing your teeth?*

Is there anything about your smile or bite that you would wish to change?*

What are your concerns (if any) about having dental treatment?*

Dental Information

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