Dental History Form 1Patient Information2Current Health3Past Diasnoses4Lifestyle5Wrapup and signature67 Patient name* First Middle Last Preferred name Date* 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 MM slash DD slash YYYY Date of last cleaning MM slash DD slash YYYY Date of last dental x-rays MM slash DD slash YYYY Have you had complications with previous dental treatment? No Yes Do you have any specific goals with your dental treatment? No Yes If yes, please explainIs there anything you strongly dislike about coming to the dentist? No Yes If yes, please explainIs there anything you would like to discuss with Dr. Beck privately? No Yes If yes, please explain Periodontal HistoryHow often do you brush your teeth? How often do you floss? Have you ever had a full periodontal charting? No Yes Have you ever needed: deep cleaning, SRP, scaling or root planing? No Yes Have you ever had gum treatment, surgery or grafting? No Yes Do your gums bleed when you brush or floss? No Yes What kind of toothbrush do you use? Do you suffer from bad breath (halitosis)? No Yes Dental HistoryDo you currently have a toothache, sensitivity or discomfort? No Yes If yes, describe pain, area, duration Do you have any loose teeth? No Yes If yes, describe area Does food get caught in your teeth? No Yes If yes, where? Have you ever had braces? No Yes If yes, when and for how long? Are your wisdom teeth removed? No Yes If yes, how many and at what age? Any other teeth removed or lost (other than wisdom teeth)? No Yes If yes, are you interested in a permanent replacement? No Yes TMJ ProfileDo you clench or grind your teeth? No Yes Does your jaw pop or click? No Yes Do you have pain or soreness in your face muscles or around your ears? No Yes Do you have frequent headaches, neck aches or shoulder aches? No Yes Do you or have you worn a splint or night guard? No Yes Cosmetic ProfileDo you have any chipped/broken teeth? No Yes If yes, are you interested in repair? No Yes Are you happy with the appearance of your teeth? No Yes Are you interested in changing the appearance? No Yes If 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 document Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. Δ
