Dental History New Patients Form Dental History Your Name Your Phone Number Your Email How do you feel about dental treatment? Relaxed A little Uneasy Tense Anxious Very Anxious Have you seen a dentist before? Yes No If so, when was your last dental visit? Within the last 3-6 months Within the last 6-9 months Within the last 9-12 months More than 1 year More than 2 years More than 5 years Never How would you rate your previous dental experience? Excellent Good Average Poor What are your dental concerns? Have you avoided regular dental care? Yes No If so, why have you avoided regular dental care? Are you happy with the appearance of your teeth? Yes No If not, why are you unhappy with the appearance of your teeth? How often do you brush? Less than once per week Once per week Several times per week Once per day Twice per day Three times per day How often do you floss? Less than once per week Once per week Several times per week Once per day Twice per day Three times per day How often do you use other aids? Less than once per week Once per week Several times per week Once per day Twice per day Three times per day Would you like your teeth to be whiter? Yes No Would you like your teeth to be straighter? Yes No Do you have, or have you ever had any of the following dental conditions? Please check all that apply. Aching or sensitive teeth Active decay of teeth or gums Areas of food traps Bad breath Broken filling Broken or missing teeth Cavities Clicking or popping jaw Cold sores Difficulty opening wide Dry mouth Aesthetic concerns with teeth Facial Surgery Gag Easily Growths & lesions in your mouth Gum Infection/Disease Gum Treatments Jaw Pain or Tiredness Jaw Clenching Loose Teeth Night Guard Oral Surgery Orthodontic Treatment Sensitive or bleeding Gums Swelling or Lumps in Mouth Swollen Glands Teeth Grinding Unfavorable Dental Experience None Of the Above Name of previous dentist or dental office City State / Province To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in status. Submit Your Request Insurance InformationCheck it out
