Name Name * Nickname * Age * Referred by How would you rate the condition of your mouth? * Excellent Good Fair Poor Previous Dentist How long have you been a patient? (Months/Years) Date of most recent dental exam Date of most recent x-rays Date of most recent treatment (other than a cleaning) I routinely see my dentist every: PLEASE SELECT... 3 months 4 months 6 months 12 months Not routinely WHAT IS YOUR IMMEDIATE CONCERN? PLEASE ANSWER YES OR NO TO THE FOLLOWING: PERSONAL HISTORY 1. Are you fearful of dental treatment? 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? Yes No 6. Have you had any teeth removed? Yes No GUM AND 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 sensation in your mouth? 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 (i.e. pitting, craters) on the biting surface of your teeth? Yes No 17. Are any teeth sensitive to hot, cold, biting, sweets, or 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 bite your 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. Have your teeth changed in the last 5 years, become shorter, thinner or worn? 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 more than one bite, squeeze, or shift your jaw to make your teeth fit together? Yes No 28. Do you place your tongue between your teeth or rest 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 your teeth in the daytime or make them sore? Yes No 31. Do you have any problems with sleep (i.e. restlessness), 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? 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 ACCEPTANCE Patients Signature Date Doctor’s Signature Date
