Swanson Dental - Dental History Form
Swanson Dental - Dental History Form
Name
Name
*
First
Last
Nickname (if different than first name)
Email
*
Phone
Phone
-
###
-
###
####
Age
*
Referred by
How would you rate the conditions of your mouth?
*
Excellent
Good
Fair
Poor
Previous Dentist
Previous Dentist
*
First
Last
How long have you been a patient? (Years/Months)
*
Last Dental Exam
Last Dental Exam
*
/
MM
/
DD
YYYY
Last X-rays
Last X-rays
*
/
MM
/
DD
YYYY
Last Treatment (other than cleaning)
Last Treatment (other than cleaning)
/
MM
/
DD
YYYY
How often do you see the dentist?
*
Every 3 Months
Every 4 Months
Every 6 Months
Every 12 Months
Not Regularly
What is your immediate concern?
PERSONAL HISTORY
1. Are you fearful of dental treatment?
*
YES
NO
How fearful? On a scale of 1 (least) to 10 (most)?
1
2
3
4
5
6
7
8
9
10
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?
6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?
*
YES
NO
GUM & BONE
7. Do your gums bleed or are they painful when brushing or flossing?
*
YES
NO
8. Have you ever been treated for gum disease 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?
*
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 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?
*
YES
NO
16. Do you feel or notice any holes (ie. 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 & 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 need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
*
YES
NO
28. Do you place your tongue between your teeth or close your teeth against your tongue?
*
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 together in the daytime or 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 teeth that you would like to change (shape, color, size)?
*
YES
NO
34. Have you ever whitened (bleached) your teeth?
*
YES
NO
35. Have you felt uncomfortable or self conscious about the appearance of your teeth?
*
YES
NO
36. Have you been disappointed with the appearance of previous dental work?
*
YES
NO
PATIENT'S SIGNATURE
*
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.