Dental History Questionnaire
Do you have or have you had any concerning areas in your mouth?
Yes
No
Date of last Dental Visit
-
Month
-
Day
Year
Date
Date of last cleaning
-
Month
-
Day
Year
Date
Date of last full mouth X-Ray
-
Month
-
Day
Year
Date
What is the most important thing we can do for you today?
Do you have areas in your mouth that concern you?
Yes
No
Please Explain
Are any of your teeth sensitive to
Hot
Cold
Sweets
Pressure
Other
Have you had
Orthodontic Treatment
Oral Surgery
Periodontal Treatment
Have you noticed
Loosening of your teeth
Food catching between your teeth
Pain/swelling of your gums
Bad breath
Sores in your mouth
Bleeding with brushing or flossing
Have you experienced
Clicking of the jaw
Pain (Joint, Ear, Side of Face)
Difficulty opening/closing
Difficulty chewing
Do you
Clench or grind your teeth
Bite your lips or cheeks
Breathe through your mouth
Use marijuana or tobacco products
What are your expectations of this office?
What's most important to you in a relationship with your dentist?
How long do you want to keep your teeth?
What would you like to change about the appearance of your mouth/teeth?
Do you prefer to know all the details about your dental care or would you prefer to know about the big picture/overview?
General Consent
At our office, we like to take before and after pictures of dental work Dr. Patterson has done. At this time we would like to ask if it is okay to use pictures of you and your dental work in advertising and marketing materials without showing your face?
Yes
No
May we show your face?
Yes
No
Name
*
First Name
Last Name
Patient Signature (Parent or Guardian if minor)
*
Clear
Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
Should be Empty: