Dental History Form

 

The information provided on this form is important to your dental health. Please complete all of questions to the best of your ability. If there have been any changes in your health, please tell us. Questions are welcome and appreciated.

Contact Information

Patient First Name: *

 

Last Name: *

 

Patient Email: *


Dental History

Why have you come to the dentist today?

Do you require antibiotics before dental treatment?

Yes No  

Are you currently in pain?

Yes No  

Have you had a serious / difficult problem associated
with any previous dental work?

Yes No  

Do you have fears about going to the dentist?

Yes No  

Have you ever had gum disease?

Yes No  

Do you now or have you ever experienced pain /
discomfort in your jaw joint (TMJ / TMD)?

Yes No  

Your current dental health is:

Excellent Good Fair Poor  

How many times a week do you brush?

 

Do you like your smile?

Yes No  

 

How many times a day do you floss?

 

Do your gums bleed?

Yes No  

 

Type of bristles?

Soft Medium Hard  

How long do you use a toothbrush before replacing it?

Are your teeth sensitive to heat, cold, or anything else?

Have you lost any teeth?

Yes No  

 

If yes, why?

 


By submitting this form I am giving my informed consent as follows. To the best of my knowledge the information given above is correct. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment.

 
 

It may take a moment to submit your information. Please wait for a confirmation message.

 

OHIOSmiles

1500 Deerpath Drive
Cambridge, OH 43725

(740) 630-9797

Opening Hours

Monday & Tuesday: 8am–4pm
Wednesday: 11am–7pm
Thursday: 8am–4pm
Friday: 7am–3pm

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