Patient Dental History Bringing your best smile to life Contact us Patient Dental History FormMedical History FormInsurance Information FormOffice Policy Form Patient Dental History URLThis field is for validation purposes and should be left unchanged.Legal Name(Required)Preferred nameDate of Birth MM slash DD slash YYYY What are your pronounsLegal sex for insurance purposesReason for VisitReferred byLast dental visitTreatment provided at that timeFrequency of dental visitsPrevious dentist (name and location)Have you had a complete series of dental films/x-rays taken?When?LocationCan we request these be sent to our office?Please indicate Yes (Y) or No (N) to the following:Do your gums bleed while brushing of flossing? YES NO Are your teeth sensitive to hot or cold? YES NO Do you feel pain in any of your teeth? YES NO Do you have any sores or lumps in or near your mouth? YES NO Have you ever had any head, neck, or jaw Injuries? YES NO Do you bite your lips/cheeks frequently? YES NO Have you noticed any loosening of your teeth? YES NO Have you had periodontal (gum) treatment? YES NO Have you received oral hygiene instruction for the care of your teeth and gums? YES NO Have you had prolonged bleeding following extractions? YES NO Have you experienced any of the following problems?Clicking YES NO Pain (joint, ear or side of face) YES NO Difficulty in opening or closing YES NO Difficulty in chewing? YES NO Do you have frequent headaches? YES NO Do you clench or grind your teeth? YES NO Other treatmentsDo you wear dentures or partials? YES NO Date of placement of dentures or partials?Do you have dental implants? YES NO Date of placement of dental implantsHave you had orthodontic treatment? YES NO Date of completing orthodontic treatmentHave you had treatment from a dental specialist? YES NO What type of treatment have you had?Do you have any additional comments or concerns?Patient/Parent/Guardian Signature(Required) Δ Patient Dental History FormMedical History FormInsurance Information FormOffice Policy Form
(250) 721-2221
(250) 721-2221