Dental History Form

1Patient Information

2Current Health

3Past Diasnoses

4Lifestyle

5Wrapup and signature

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This field is for validation purposes and should be left unchanged.

Patient name*

First Middle Last

Preferred name

Date*

Purpose of today's visit:*

Any other dental problems or concerns you would like to address?

Past Dental Experience

Previous Dentist Name

First Last

Previous Dentist Address

Street Address Address Line 2 City State ZIP Code

Previous Dentist Phone

How often do you go to the dentist?

Date of last dental visit

Date of last cleaning

Date of last dental x-rays

Have you had complications with previous dental treatment?

Yes

Do you have any specific goals with your dental treatment?

Yes

If yes, please explain

Is there anything you strongly dislike about coming to the dentist?

Yes

If yes, please explain

Is there anything you would like to discuss with Dr. Beck privately?

Yes

If yes, please explain

TMJ & bruxism treatment

Root canal therapy

Tooth-colored fillings

Teeth whitening

Porcelain veneers

Same-day crowns

Dental crowns

Dental bridges

Dental implants

SureSmile

Past Dental Experience

Periodontal History

Dental History

TMJ Profile

Cosmetic Profile

I certify that the above information is complete and accurate

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