Dental History Form 1 Patient Information2 Current Health3 Past Diasnoses4 Lifestyle5 Wrapup and signature6 7 Patient name First Middle Last Preferred nameDate Date Format: MM slash DD slash YYYY Purpose of today's visit:Any other dental problems or concerns you would like to addressed? Past Dental ExperiencePrevious Dentist Name First Last Previous Dentist Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Dentist PhoneHow often do you go to the dentist?Date of last dental visit Date Format: MM slash DD slash YYYY Date of last cleaning Date Format: MM slash DD slash YYYY Date of last dental x-rays Date Format: MM slash DD slash YYYY Have you had complications with previous dental treatment?NoYesDo you have any specific goals with your dental treatment?NoYesIf yes, please explainIs there anything you strongly dislike about coming to the dentist?NoYesIf yes, please explainIs there anything you would like to discuss with Dr. Beck privately?NoYesIf yes, please explain Periodontal HistoryHow often do you brush your teeth?How often do you floss?Have you ever had a full periodontal charting?NoYesHave you ever needed: deep cleaning, SRP, scaling or root planing?NoYesHave you ever had gum treatment, surgery or grafting?NoYesDo your gums bleed when you brush or floss?NoYesWhat kind of toothbrush do you use?Do you suffer from bad breath (halitosis)?NoYes Dental HistoryDo you currently have a toothache, sensitivity or discomfort?NoYesIf yes, describe pain, area, durationDo you have any loose teeth?NoYesIf yes, describe areaDoes food get caught in your teeth?NoYesIf yes, where?Have you ever had braces?NoYesIf yes, when and for how long?Are your wisdom teeth removed?NoYesIf yes, how many and at what age?Any other teeth removed or lost (other than wisdom teeth)?NoYesIf yes, are you interested in a permanent replacement?NoYes TMJ ProfileDo you clench or grind your teeth?NoYesDoes your jaw pop or click?NoYesDo you have pain or soreness in your face muscles or around your ears?NoYesDo you have frequent headaches, neck aches or shoulder aches?NoYesDo you or have you worn a splint or night guard?NoYes Cosmetic ProfileDo you have any chipped/broken teeth?NoYesIf yes, are you interested in repair?NoYesAre you happy with the appearance of your teeth?NoYesAre you interested in changing the appearance?NoYesIf yes, describe changes you would like made to your teeth/smile I certify that the above information is complete and accurateYOUR SIGNATURE OR PATIENT’S/GUARDIAN’S SIGNATURE*By typing your full name here, you are electronically signing this documentDate* Date Format: MM slash DD slash YYYY
