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.)___________________________
_____________________________________________________________________________________
Do you have any dental problems now? If yes, please describe___________________________________
_______________________________________________________________________
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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