Dental History

Full Name:*

What is the main purpose of your visit today?*

Are there any other details about this visit?

My last dental checkup was:

My last scaling and/or cleaning was

My last dental radiograph (X-ray) was:

How often do you normally see a detist?

Have you ever had problems with dental treatment?

yes
no

Do your gums ever bleed or feel tender or sore?

yes
no

Would you like information on simple and effective ways to make your teeth whiter than is possible with a scale & clean?

yes
no

Would you like to improve the shape, position (e.g. crooked teeth) or size of your teeth that show when you smile*

yes
no

If answered yes to the question above, what would you like to improve:

shape
position
size

Do you have any concerns about silver amalgam:

yes
no

Would you like to consider replacement of any amalgam fillings that you have:

yes
no

Are you aware of any clenching or grinding of your teeth

yes
no

Do you have frequent headaches, earaches, or stiffness/soreness in the neck or jaw joints*

yes
no

If yes, what types of aches do you experience

headache
earache
neck ache
jaw ache