In order to aid in evaluating your dental health thoroughly and completely, please complete the following questionnaire. This will become part of your office record and will be held in strict confidence. Since periodontal disease is produced by a combination of many complex elements, it is necessary to resolve every possible contributing factor. The success of therapy is dependent upon this. Though some of the following questions may seem unrelated to your gum condition, they are all associated with proper management of your oral health.

Name

Today's Date

Name of Regular DDS

How long a patient

Main dental complaint or dental problem

How long have you known about your gum condition?

What kind of gum treatment have you had previously?

None

Regular Cleanings

Deep Cleaning/scaling

Gum surgery

When was your last dental cleaning?

How many times have you had your teeth cleaned in the last three years?

Have you lost any teeth?

About when?

If yes, why?

Any problems with the tooth extractions?

Do you wear any replacement dental prosthesis?

Cemented Bridges

Removable Bridges

Complete Dentures

Have you had bad breath at times?

Yes

No

Have you had bleeding or hurting when you brush or eat?

Yes

No

Have you had pocketing or bone loss around your teeth?

Yes

No

Have you had sensitivity to hot, cold, or sweets?

Yes

No

Does food generally wedge between certain teeth?

Yes

No

If so, where?

If you had braces, when did you have them?

If you had root canal therapy, when did you have it?

If you had oral surgery, when did you have it?

Has fear or discomfort kept you from regular dental visits?

Yes

No

Do you experience anxiety or gagging during dental procedures?

Yes

No

Have you had any trouble in a dental procedure, including a reaction with anesthetic?

Yes

No

If so, describe.

Are you happy with the appearance of your teeth and/or gums?

Yes

No

If not, why not?

Do you have history of early tooth loss in your family?

Yes

No

Does your jaw click, crackle, pop or make grating noises?

Yes

No

Have you experienced any pain or soreness in the muscles of your face or around the ear?

Yes

No

Do you have frequent "tension" headaches? Do you clench or grind your teeth?

Yes

No

Do your jaws feel stiff, sore or tired when you awaken? Do your jaws feel tired at the end of the day?

Yes

No

Have you noticed any loose, shifting, or tipped teeth?

Yes

No

For the following, please fill in the type of item you use, and how often you use it to clean your mouth.

Tooth

Tooth paste

Dental floss

Rubber tip

Toothpicks

Mouthwash

Electric toothbrush

Water Pik

Other

How would you rate your past dental care?

Is there anything else or anything special you think I should know about your dental history?