New Patient Forms Dental HistoryName First Last Previous Dentist Name When was your last visit to the dentist? When were your last full mouth x-rays taken? How would you rate your smile?ExcellentNeeds ImprovementIf you had a magic wand, what would you change about your smile? What, if any, would keep you from having dental treatment completed? Fear Finances Pain Time Check all that apply Have you ever had any serious trouble associated with previous dentistry? Have you ever been diagnosed or treated for periodontal disease? (gum disease, pyorrhea, trench mouth) Does dental treatment make you nervous?NoSlightlyModeratelyExtremelyHow often do you brush your teeth? Floss? Toothbrush is:SoftMediumHardElectricPlease check if you have or have had any of the following: Bleeding/Sore Gums Unpleasant Taste/Bad Breath Clicking or Popping Jaw Food Collection between Teeth Biting Cheeks/Lips Snoring Stained Teeth Missing Teeth Partial Dentures Clenching/Grinding Teeth Loose Teeth or Broken Fillings Sensitivity when Biting Sores or Growths in your Mouth Frequent Blisters on Lips/Mouth Mouth Piercing Ringing in Ears Achy Pain in Teeth Complete Dentures Sensitivity to Heat Sensitivity to Sweets Sensitivity to Cold Orthodontics Difficulty opening or closing Jaw Pain in your Jaw Joint or your Face/Ear Chipped or Broken Teeth Throbbing Pain Dental Implants Δ
