You can still download the fillable PDF here, and print to bring with you to your appointment. Name* First Last NicknameEmail* Age*Referred byHow would you rate the condition of your mouth?* Excellent Good Fair Poor Previous dentistHow long have you been a patient?*Months/YearsDate of most recent dental exam MM slash DD slash YYYY Date of most recent X-rays MM slash DD slash YYYY Date of most recent treatment (other than cleaning) MM slash DD slash YYYY I routinely see my dentist every:* 3 months 4 months 6 months 12 months Not routinely What is your immediate concern?*Please answer YES or NO to the following:PERSONAL HISTORYAre you fearful of dental treatment?* Yes No How fearful,on a scale of 1 (least) to 10 (most)*Please enter a number from 1 to 10.Have you had an unfavorable dental experience?* Yes No Have you ever had complications from past dental treatment?* Yes No Have you ever had trouble getting numb or had any reactions to local anesthetic?* Yes No Did you ever have braces, orthodontic treatment or had your bite adjusted?* Yes No At what age?*Have you had any teeth removed or missing teeth that never developed or lost teeth due to injury or facial trauma?* Yes No GUM AND BONEDo your gums bleed or are they painful when brushing or flossing?* Yes No Have you ever been treated for gum disease or been told you have lost bone around your teeth?* Yes No Have you ever noticed an unpleasant taste or odor in your mouth?* Yes No Is there anyone with a history of periodontal disease in your family?* Yes No Have you ever experienced gum recession?* Yes No Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?* Yes No Have you experienced a burning or painful sensation in your mouth not related to your teeth?* Yes No TOOTH STRUCTUREHave you had any cavities within the past 3 years?* Yes No Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?* Yes No Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?* Yes No Are any teeth sensitive to hot, cold, biting, sweets,or do you avoid brushing any part of your mouth?* Yes No Do you have grooves or notches on your teeth near the gum line?* Yes No Have you ever broken teeth,chipped teeth, or had a toothache or cracked filling?* Yes No Do you frequently get food caught between any teeth?* Yes No BITE AND JAW JOINTDo you have problems with your jaw joint? (pain, sounds, limited opening,locking, popping)* Yes No Do you feel like your lower jaw is being pushed back when you bite your back teeth together?* Yes No Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars,or other hard,dry foods?* Yes No In the past 5 years, have your teeth changed (become shorter,thinner or worn) or has your bite changed?* Yes No Are your teeth becoming more crooked,crowded,or overlapped?* Yes No Are your teeth developing spaces or becoming more loose?* Yes No Do you have trouble finding your bite,or need to squeeze,tap your teeth together, or shift your jaw to make your teeth fit together?* Yes No Do you place your tongue between your teeth or close your teeth against your tongue?* Yes No Do you chew ice, bite your nails, use your teeth to hold objects,or have any other oral habits?* Yes No Do you clench or grind your teeth together in the daytime or make them sore?* Yes No Do you have any problems with sleep (i.e. restlessness or teeth grinding), wakeup with a headache or an awareness of your teeth?* Yes No Do you wear or have you ever worn a bite appliance?* Yes No SMILE CHARACTERISTICSIs there anything about the appearance of your teeth that you would like to change (shape, color, size)?* Yes No Have you ever whitened (bleached) your teeth?* Yes No Have you felt uncomfortable or self conscious about the appearance of your teeth?* Yes No Have you been disappointed with the appearance of previous dental work?* Yes No Patient's SignatureCAPTCHANameThis field is for validation purposes and should be left unchanged.
