Skip to content
HOME
ABOUT
SERVICES
INTAKE FORMS
BLOG
CONTACT
Form – Patient Dental History
Sam
2020-12-30T16:35:08-08:00
Patient Dental History
Patient Dental History Form
Medical History Form
Insurance Information Form
Office Policy Form
Patient Dental History
Legal Name
*
Preferred name
Date of Birth
MM slash DD slash YYYY
What are your pronouns
Legal 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 Form
Medical History Form
Insurance Information Form
Office Policy Form
Page load link
Go to Top