Dental Health History Form

Please complete this form to help us provide you with the best dental care possible. All information is confidential.

First name

Last name

Date of Birth

Reason for today's visit

Previous dentist name and location

Date of Last Dental Visit

Date of Last X-Rays Taken

Select any issues you have experienced or you're currently experiencing Current or past dental concerns (check all that apply)

Bleeding gums

Bad breath

Blisters on lips or mouth

Burning sensation on tongue

Chew on one side of mouth

Cigarette, pipe, cigar smoking or chew tobacco

Clicking or popping jaw

Dry mouth

Fingernail Biting

Food collecting between teeth

Foreign Objects

Grinding teeth

Gums swollen or tender

Jaw pain or tiredness

Lip or cheek biting

Loose teeth or broken fillings

Mouth breathing

Mouth pain brushing

Orthodontic treatment

Pain around ear

Periodontal treatment

Sensitivity to cold

Sensitivity to heat

Sensitivity to sweets

Sensitivity when biting

Sores or growths in mouth

None of the above

Other concern

How often do you brush?

How often do you floss?

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