Dental History Form - Jensen Lakes Dental

GENERAL INFORMATION

Patient First Name *

Patient Last Name *

Email Address *

Phone Number *

Referred By

Previous Dentist

For How Long

I Have Routinely Seen My Dentist Every3-4 Months6 Months12 MonthsNot Often

What is your Immediate Concern? *

How would you Rate the Condition of your Mouth? *ExcellentGoodFairPoor

Are you Fearful of Dental Treatment? *

How Fearful? (1-10) *

Have you Ever had an Unfavourable 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 Any That Apply to YouBloody 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 Any That Apply to YouCavities 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

MEDICAL HISTORY

Name of Physician and Their Personality

Name of Recent Physical Examination and Purpose

Do You or Have You Ever HadHospitalization for Illness or Injury?

Reason

If Other, Please Specify:

Please Explain and Date the Above Selected Items:

Are You:

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 Take Within the Last Two Years: