Dental Health - PatientPop



Dental Health

What is the reason for your visit today? _____________________________________________________

Date of Last Dental Visit__________Last Dental Cleaning___________Last Full Mouth X-ray_________

What was done at your last dental visit? _____________________________________________________

Previous Dentist_____________________________________________Phone Number_______________

Address___________________________________________State_________________Zip____________

How often do you brush your teeth? ______________________How often do you floss? ____________

How often do you have dental examinations? ________________________________________________

What other dental aids do you use? (water pick, electric toothbrush, etc.)___________________________

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Do you have any dental problems now? If yes, please describe___________________________________

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Are any of your teeth sensitive to: Have you ever had?

Hot or cold Y N Orthodontic treatment Y N

Sweets Y N Oral surgery Y N

Biting or chewing Y N Periodontal treatment Y N

Mouth odor or bad taste Y N Your bite adjusted Y N

Do you frequently get cold sores A bite plane or mouth guard Y N

Blisters or any oral lesions Y N Serious injury to mouth or head Y N

Do your gums bleed or hurt Y N If so describe the cause:

Have your parents experienced

Gum disease or tooth loss Y N Have you ever experienced:

Have you noticed any loose Clicking or popping in jaw Y N

Teeth or change in your bite Y N Pain (ears, joint, side of face) Y N

Difficulty in opening or closing

Do you: the mouth Y N

Clench or grind your teeth while Headaches, neck or shoulder

Asleep or awake Y N pain Y N

Bite your lips or cheeks Y N Difficulty chewing on either

Mouth breathe Y N side of mouth Y N

Snore or sleep disorder Y N Are you satisfied with your

Smoke/Chew Y N your teeth’s appearance Y N

Would you like to keep all of

your teeth all of you life? Y N

How would you rate your smile? Worst 1 2 3 4 5 6 7 8 9 10 Best

Is there anything else about having dental treatment that you would like to know? Y N Explain:

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