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?
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?