Dental History Form

Dental History

How would you rate the condition of your mouth?
MM slash DD slash YYYY
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I routinely see my dentist every:

Personal History

Are you fearful of dental treatment?
Have you had an unfavorable dental experience?
Have you ever had complications from past dental treatment?
Have you ever had trouble getting numb or had any reactions to local anesthetic?
Did you ever have braces, orthodontic treatment or had your bite adjusted?
Have you had any teeth removed?

Smile Characteristics

Is there anything about the appearance of your teeth that you would like to change?
Have you ever whitened (bleached) your teeth?
Have you felt uncomfortable or self-conscious about the appearance of your teeth?
Have you been disappointed with the appearance of previous dental work?

Bite and Jaw Joint

Do you have problems with your jaw joint? (pain, sounds, limited opening, locking or popping)
Do you/would you have any problems with chewing gum?
Do you/would you have any problems chewing bagels, baguettes or other hard food?
Have your teeth changed in the last 5 years, become shorter, thinner or worn?
Are your teeth crowding or developing spaces?
Do you have more than one bite and squeeze to make your teeth fit together?
Do you chew ice, bite your nails, use your teeth to hold objects or have any other oral habits?
Do you clench your teeth in the daytime or make them sore?
Do you have any problems with sleep or wake up with an awareness of your teeth?
Do you wear or have you ever worn a bite appliance?

Tooth Structure

Have you had any cavities within the past 3 years?
Does the amount of saliva in your mouth seem low or do you have difficulty swallowing food?
Do you feel or notice any holes (pitting or craters) on the biting surface of your teeth?
Are any teeth sensitive to hot, cold, sweets or do you avoid brushing any part of your mouth?
Do you have grooves or notches on your teeth near the gum line?
Have you ever broken teeth, chipped teeth, had a toothache or cracked filling?
Do you get food caught between any teeth?

Gum and Bone

Do your gums bleed when brushing or flossing?
Have you ever been treated for gum disease or been told you have lost bone around your teeth?
Have you ever noticed an unpleasant taste or odor in your mouth?
Is there anyone with a history of periodontal disease in your family?
Have you ever experienced gum recession?
Have you ever had any teeth become loose on their own?
Have you experienced a burning sensation in your mouth?
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Sarah Palmer DDS and Amy Harmon DDS are able to restore teeth to their natural appearance and function with porcelain crowns or other cosmetic dental services. If you are interested in learning if you are a candidate for our porcelain crown treatments, call our cosmetic dentists at (616) 534-0080.

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