Call 858-249-4441
Please enable JavaScript in your browser to complete this form.

Dental History Form

To complete this Dental History Form, simply fill out the fields with the requested information. While most of the fields are optional, certain fields marked by asterisks (*) must be completed. Please do not use your browser's Back or Forward buttons. Use of these buttons may “undo”/”redo” recent actions. Once you have completed this document, simply click the submit button to proceed.

Name
Do you know the name of your previous dentist?
Do you know the date of your most recent dental exam?
Do you know the date of your most recent x-rays?
Do you know the date of your most recent treatment (not a cleaning)?
How often do you routinely see the dentist?
Are you fearful of dental treatment?
On a scale of 1 (least) to 10 (most), what range do you fall into on fearfulness?
Have you ever had an unfavorable dental experience?
Ever had complications from past dental treatment?
Have you ever had trouble getting numb or had any reaction to local anesthetic?
Did you ever have braces, orthodontic treatment or had your bite adjusted?
Have you had any teeth removed?
Do you have an immediate dental concern?
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking or popping)?
Do you/ have any problems chewing bagels, baguettes, protein bars, or other hard foods?
Have your teeth changed in the last 5 years, become shorter, thinner or worn out?
Are your teeth crowding or developing spaces?
Do you have more than one bite and squeeze to make your teeth fit together?
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
Do you clench your teeth in daytime/make them sore?
Do you have any problems with sleep or wake up with an awareness of your teeth?
Do you or have you ever worn a bite appliance?
Have you had any cavities within the past 3 years?
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
Are any teeth sensitive to hot, cold, biting, sweets or do you avoid brushing any part of your mouth?
Do you have grooves or notches on your teeth near the gum line?
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
Do you frequently get food caught between teeth?
Do your gums bleed or are they painful when brushing or flossing?
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
Have you ever noticed an unpleasant taste or odor in your mouth?
Is there anyone with a history of periodontal disease in your family?
Have you ever experienced gum recession?
Have you ever had any teeth become loose on their own (without an injury), or have difficulty eating an apple?
Have you had a burning sensation in your mouth?
Is there anything about the appearance of your teeth that you would like to change?
Have you ever whitened (bleached) your teeth?
Have you felt uncomfortable or self conscious about the appearance of your teeth?
Have you been disappointed with the appearance of previous dental work?

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Please draw your signature in the box. Use the X to clear your signature.

Please carefully review your information before submitting this document.