Dental History

Dental Care on Golf Links
8975 E. Golf Links Rd
Tucson AZ, 85730

Dental History

"*" indicates required fields

Name*

How would you rate your mouth?

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Excellent

Good

Fair

Poor

Previous Dentist*

I routinely see my dentist every:

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3 mo

4 mo.

6 mo.

12 mo.

Date of most recent dental exam*

Date of most recent x-rays*

Date of most recent treatment (other than a cleaning)*

WHAT IS YOUR MOST IMMEDIATE CONCERN?

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PLEASE ANSWER YES OR NO TO THE FOLLOWING:

Yes No

PERSONAL HISTORY

1. Are you fearful of dental treatment? How fearful, 1 (least) to 10 (most)

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2. Have you had an unfavorable dental experience?

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3. Have you ever had complications from past dental treatment?

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4. Have you ever had trouble getting numb or had any reactions to local anesthetic?

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5. Did you ever have braces, orthodintic treatment or had your bite adjusted?

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6. Have you had any teeth removed?

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GUM AND BONE

7. Do your gums bleed or are they painful when brushing or flossing?

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9. Have you ever noticed an unpleasant taste or odor in your mouth?

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10. Is there anyone with a history of periodontal disease in your family?

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11. Have you ever experienced gum recession?

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12. Have you ever had any teeth become loose on their own (without any injury), or do you have difficulty eating an apple?

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13. Have you experienced a burning sensation in your mouth?

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TOOTH STRUCTURE

14. Have you had any cavities in the past 3 years?

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15. Does the amount of saliva in your mouth seem too little or do you have any difficulty swallowing food?

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16. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?

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17. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?

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18. Do you have grooves or notches on your teeth near the gumline?

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19. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?

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20. Do you frequently get food caught between any teeth?

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BITE AND JAW JOINT

20. Do you frequently get food caught between any teeth?

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