Referred by
Previous Dentist
How long have you been a patient?   Months Years
 Date of most recent dental exam
Date of most recent x-rays
Date of most recent treatment
(other than a cleaning)
I routinely see my dentist every: 3 mo. 4 mo. 6 mo. 12 mo. Not routinely
How would you rate the condition of your mouth? Excellent  Good  Fair  Poor




 Yes  No    1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most):

 Yes  No    2. Have you had an unfavorable dental experience?

 Yes  No    3. Have you ever had complications from past dental treatment?

 Yes  No    4. Have you ever had trouble getting numb or had any reactions to local anesthetic?

 Yes  No    5. Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?

 Yes  No    6. Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma?


 Yes  No   7. Do your gums bleed or are they painful when brushing or flossing?

 Yes  No    8.Have you ever been treated for gum disease or been told you have lost bone around your teeth?

 Yes  No    9. Have you ever noticed an unpleasant taste or odor in your mouth?

 Yes  No    10. Is there anyone with a history of periodontal disease in your family?

 Yes  No    11. Have you ever experienced gum recession?

 Yes  No    12. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?

 Yes  No    13. Have you experienced a burning or painful sensation in your mouth not related toyour teeth?


 Yes  No    14. Have you had any cavities within the past 3 years?

 Yes  No    15. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

 Yes  No    16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?

 Yes  No    17. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?

 Yes  No    18. Do you have grooves or notches on your teeth near the gum line?

 Yes  No    19. Have you ever broken teeth, chipped teeth, or had atoothache or cracked filling?

 Yes  No    20. Do you frequently getfood caught between any teeth?


 Yes  No    21. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

 Yes  No    22. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?

 Yes  No    23. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?

 Yes  No    24. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?

 Yes  No    25. Are your teeth becoming more crooked, crowded, or overlapped?

 Yes  No    26. Are your teeth developing spaces or becoming more loose?

 Yes  No    27. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?

 Yes  No    28. Do you place your tongue between your teeth or close your teeth against your tongue?

 Yes  No    29. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?

 Yes  No    30. Do you clench or grind your teeth together in the daytime or make them sore?

 Yes  No    31. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?

 Yes  No    32. Do you wear or have you ever worn a bite appliance?


 Yes  No    33. Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?

 Yes  No    34. Have you ever whitened (bleached) your teeth?

 Yes  No    35. Have you felt uncomfortable or self conscious about the appearance of your teeth?

 Yes  No    36. Have you been disappointed with the appearance of previous dental work?


Patient’s Signature Date
Doctor’s Signature