DOB dental history
Dentistry On Bleams
Dental History
Dentistry On Bleam History
Patient Name
Patient Name
First
First
Last
Last
How would you rate the condition of your mouth? (good, excellent, bad))
Date of most recent dental exam
Date of most recent x-rays
Date of most recent treatment (other than cleaning)
I routinely see my dentist every:
WHAT IS YOUR IMMEDIATE CONCERN?
Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)
Have you had an unfavourable 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
Have you had any teeth removed?
yes
no
Is there anything about the appearance of your teeth that you would like to change?
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
Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
yes
no
Do you / would you have any problems chewing gum?
yes
no
Do you / would you have any problems chewing bagels, baguettes , protein bars, or other hard foods?
yes
no
Have your teeth changed in the last 5 years, become shorter, thinner or worn?
yes
no
Are your teeth crowding or developing spaces?
yes
no
Do you have more than one bite and squeeze to make your teeth fit together?
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 your teeth in the daytime or make them sore?
yes
no
Do you have any problems with sleep or wake up with an awareness of your teeth?
yes
no
Do you wear or have you ever worn a bite appliance?
Have 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, and sweets, or avoid brushing any part of your mouth?
yes
no
Do you have grooves or notches on your teeth near the gum line?
yes
no
Do you feel or notice any holes (i.e., pitting, craters) on the biting surface of your teeth?
yes
no
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
yes
no
Do you get food caught between any teeth?
yes
no
Do your gums bleed 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 odour in your mouth
yes
no
Is there anyone with a history of periodontal disease in your family?
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 ever experienced a gum recession?
yes
no
Have you experienced a burning sensation in your mouth?
yes
no
Patients Signature
Clear
Date
Doctor’s Signature
Clear
Date
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