Dental History Name: Date



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  • Dental History Name: Date:






  1. What services are you seeking?







  1. How would you describe your past dental experiences?

Good Fair Poor





  1. List your main concerns in the order of 1 to 4.

Economy_____ Time________

Quality______ Comfort_______




  1. When and what services were performed in the last dental appointment?

When________________________

Services______________________





  1. How long has it been since you had a thorough evaluation of your mouth?




  1. Teeth Cleaned? __________

  2. X-rays of your entire mouth?

___________________________

  1. A. I brush my teeth

B. floss them

__________ /day

________/week



  1. Do your gums bleed?

Y

N

  1. Have you been treated for gum disease?

Y

N

  1. Are you a smoker?

Y

N

How much? /day

  1. Have you had dental implant in the past?

Y

N

  1. Have you been treated for cosmetic?

Porcelain Veneer

All. Por crown

  1. Have you ever worn braces?

Y

N

WHEN?

  1. Are you teeth sensitive to

HOT COLD SWEET

  1. Do you clench or grind your teeth?

Y

N

  1. Have you ever had or been treated for TMJ or jaw joint problems?

Y

N

16. Is there something else that we should know about your mouth?




Signature_______________________________________ Assistant____________________________


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