Dental History Form - Jensen Lakes Dental

Patient Dental History

Patient First Name *

Patient Last Name *

Email Address *

Phone Number *

Referred by

Previous Dentist

For how long?

I have routinely seen my dentist every

3-4 Months6 Months12 MonthsNot often

How would you rate the condition of your mouth? *

ExcellentGoodFairPoor

What is your immediate concern? *

Are you fearful of dental treatment? *

How fearful? (1-10)

Have you ever had an unfavorable dental experience? *

Have you ever had complications from past dental treatment? *

Have you ever had trouble getting numb or had any reactions to local anesthesia? *

Did you ever have braces, orthodontic treatment, or have your bite adjusted? *

If yes, at what age?

Have you had any teeth removed, missing teeth that never developed, or lost teeth due to injury or facial trauma? *

Gum and Bone

Please select all that apply to you:

Bloody or painful gums when brushing or flossingPrevious gum disease or bone loss around teethUnpleasant taste or odor in mouthFamily history of periodontal diseaseGum recessionLoose teeth (without any injury) or difficulty eating an appleBurning sensation or pain in mouth not related to teeth

Tooth Structure

Please select all that apply to you:

Cavities within the past 3 yearsAmount of saliva seems to be too little or difficulty swallowing foodHoles on the biting surface of teethTeeth are sensitive to hot, cold, biting, sweets, or brushingTeeth have grooves/notches near gumlineBroken teeth, chipped teeth, or cracked filling causing toothacheFood often gets caught in between teeth

Bit and Jaw Joint

Smile Characteristics

Please select all that apply to you:

There is something about the appearance of your teeth you would like to change (shape, colour, size)You have whitened (bleached) your teethYou have felt uncomfortable or self-conscious about your teeth appearanceYou have been disappointed about the appearance of previous dental work

Medical History

Name of physician and their specialty

Most recent physical examination and purpose

What is your estimate of your general health?

Do you or have you ever had hospitalization for illness or injury?

YesNo

If yes, please specify the reason:

If other, please specify:

Please explain and date the above selected items:

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your treatment:

List all medications, supplements, and/or vitamins taken within the last two years:

Monday - Saturday

9:00AM - 4:00PM

Sunday

CLOSED

By Appointment Only