Victoria Dentist Dr. Elizabeth Watt | Cedar Tree Dental

Legal Name*

Preferred name

Date of Birth

Assigned sex for insurance purposes

Reason for Visit

Referred by

Last dental visit

Treatment provided at that time

Frequency of dental visits

Previous dentist (name and location)

Have you had a complete series of dental films/x-rays taken?

When?

Location

Can 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 treatments

Do 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 implants

Have you had orthodontic treatment?

YES
NO

Date of completing orthodontic treatment

Have 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*

Patient Dental History

Patient Dental History

Please indicate Yes (Y) or No (N) to the following:

Have you experienced any of the following problems?

Other treatments