Form:
DENTAL HISTORY MEDURE DENTAL
Page 1
Confirm
Patient Information
FIRST Name
LAST Name
MI
Dental History
Referred by
Previous Dentist
Date of most recent dental exam
Date of most recent x-rays
Date of most recent treatment
I routinely see my dentist every
3 months
4 months
6 months
12 months
Not routinely
I’ve checked all above that apply
*
How would you rate the condition of your mouth?
Excellent
Good
Fair
Poor
I’ve checked all above that apply
*
How often do you brush your teeth?
What type of toothbrush do you use?
Do you floss? If so, how often?
What is your immediate concern?
Personal History
1. Are you fearful of dental treatment? How fearful on a scale of 1(least)-10(most)
YES
NO
2. Have you had an unfavorable dental experience?
YES
NO
3. Have you ever had complications from past dental treatment?
YES
NO
4. Have you ever had trouble getting numb or had any reactions to local anesthetic?
YES
NO
5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
YES
NO
6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?
YES
NO
Gum and Bone
7. Do your gums bleed sometimes or are they ever painful when brushing or flossing?
YES
NO
8. Have you ever been treated for gum disease, had scaling and root planing, or been told you have lost bone around your teeth?
YES
NO
9. Have you ever noticed an unpleasant taste or odor in your mouth?
YES
NO
10. Is there anyone with a history of periodontal disease in your family?
YES
NO
11. Have you ever experienced gum recession, or can you see more of the roots of your teeth?
YES
NO
12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?
YES
NO
13. Have you experienced a burning or painful sensation in your mouth not related to your teeth?
YES
NO
Tooth Structure
14. Have you ever had any cavities within the past 3 years?
YES
NO
15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? Drymouth?
YES
NO
16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
YES
NO
17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
YES
NO
18. Do you have grooves or notches on your teeth near the gum line?
YES
NO
19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
YES
NO
20. Do you frequently get food caught between any teeth?
YES
NO
Bite and Jaw Joint
21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
YES
NO
22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?
YES
NO
23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
YES
NO
24. In the past 5 years, have your teeth changed (become shorter, thinner or worn) or has your bite changed?
YES
NO
25. Are your teeth becoming more crooked, crowded, or overlapped?
YES
NO
26. Are your teeth developing spaces or becoming more loose?
YES
NO
27. Do you have trouble finding your bite or do you have to shift your jaw a certain way to make your teeth fit together?
YES
NO
28. Do you place your tongue between your teeth or close your teeth against your tongues?
YES
NO
29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
YES
NO
30. Do you clench or grind your teeth in the daytime and does it make them sore?
YES
NO
31. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
YES
NO
32. Do you wear or have you ever worn a bite appliance?
YES
NO
Smile Characteristics
33. Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you like to change (shape, color, size, display)?
YES
NO
34. Have you ever bleached (whitened) your teeth? If not, are you interested?
YES
NO
35. Have you felt uncomfortable or self conscious about the appearance of your teeth?
YES
NO
36. Have you ever been disappointed with the appearance of previous dental work?
YES
NO
37. Do you know if you snore or have you ever been treated for sleep apnea?
YES
NO
38. Do you have or wear dentures or partial dentures? If so, how old are they?
YES
NO
39. What are your daily sugar habits like?
40. Do you now or have you in the past?
NO to All
Please choose YES or NO for all questions below.
Smoked
YES
NO
Used smokeless tabacco
YES
NO
Vapors
YES
NO
Marijuanna
YES
NO
41.Have you quit using these products? Please provide a quit date.
NEXT
