Patient’s Name *
Birthdate *
Reason for this visit
When was your last dental visit?
What was done then?
Previous Dentist (Name and Location)
Have you had a complete series of dental films (x-rays) taken? YesNo
If so, when/where?
How often do you brush your teeth?
How often do you floss your teeth?
Do your gums bleed while brushing or flossing? NoYes
Are your teeth sensitive to hot or cold liquids/foods? NoYes
Do you feel pain to any of your teeth? NoYes
Do you have any sores or lumps in/near your mouth? NoYes
Have you had any head/neck/jaw injuries? NoYes
Have you ever experienced any of the following problems in your jaw:
Clicking NoYes
Pain (joint, ear, side of face) NoYes
Difficulty opening or closing NoYes
Difficulty chewing NoYes
Do you have frequent headaches? NoYes
Do you have clench or grind your teeth? NoYes
Do you frequently bite your lips/cheeks? NoYes
Have you noticed any loosening of your teeth? NoYes
Does food tend to become caught between your teeth? NoYes
Have you ever had periodontal (gums) treatment? NoYes
Have you had any difficult extractions in the past? NoYes
Have you ever had any prolonged bleeding following extractions? NoYes
Do you wear dentures or partials? NoYes
If yes, date of placement:
Do you own a C-PAP machine? NoYes
If so, do you use it? NoYes
Ever worn a bite piece or other appliance? NoYes
If so, which appliance do you have? N/ANightguardOrthotic SplintSleep Anea (snore)
Do you use the above appliance? NoYes
Do you feel fatigued during the day? NoYes
Do you sleep well at night? NoYes
If you could change anything about your smile, what would you change?
I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION TO THE BEST OF MY KNOWLEDGE. ALL QUESTIONS HAVE BEEN ACCURATELY ANSWERED, I UNDERSTAND PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH. I AUTHORIZE THE DENTIST TO RELEASE ANY INFORMATION INCLUDING THE DIAGNOSIS AND RECORDS OF ANY TREATMENT OR EXAMINATION RENDERED TO ME OR MY CHILD DURING THE PERIOD OF SUCH DENTAL CARE TO THIRD PARTY PAYORS AND/OR HEALTH PRACTITIONERS. I AUTHORIZE AND REQUEST MY INSURANCE COMPANY TO PAY DIRECTLY TO THE DENTIST OR DENTAL GROUP INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I UNDERSTAND THAT MY DENTAL INSURANCE CARRIER MAY PAY LESS THAN THE ACTUAL BILL FOR SERVICES. I AGREE TO BE RESPONSIBLE FOR PAYMENT OF ALL SERVICES RENDERED ON MY BEHALF OR MY DEPENDENTS.
I Agree *
