Mountain Springs Advanced Dental

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 *
Should be Empty:

Dental History Questionnaire

General Consent