New Patient Dental History

 
 Dental History        Earlsbridge Dental

 
 Please check any of the following problems that may apply to you:

Sensitivity (hot, cold and/or sweet) ☐ Grinding or clenching teeth ☐

Tooth pain or discomfort while chewing ☐ Bleeding, swollen or irritated gums ☐

Headaches, earaches or neck pain ☐ Loose, tipped or shifting teeth ☐

Jaw joint pain (clicking/cracking) ☐ Bad breath or bad taste in your mouth ☐

Teeth or fillings breaking ☐

Do you have or had any of the following?

Dentures ☐ Braces ☐

Partial dentures ☐ Periodontal (gum) treatments ☐

Please share the following dates:

Your last hygiene appointment _____/_____

Your last oral cancer screening _____/_____

Do you smoke or use chewing tobacco? ☐ Yes ☐ No

If yes, how often? _______________ For how long? _______________

If you could change your smile, you would…

Make your teeth brighter/whiter ☐

Make your teeth straighter ☐

Close spaces ☐

Replace black metal fillings with

natural, tooth coloured fillings ☐

Repair chipped teeth ☐

Replace missing teeth ☐

Have a smile makeover ☐

Why did you leave your previous dental office?
 
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What, if anything, in the past has kept you from having dental treatment?

_____________________________________________________________________________________________
What is the most important thing to you about your future smile and dental health?

_____________________________________________________________________________________________
What is the most important thing to you about your visit today?

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