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.
Patient First Name: *
Last Name: *
Patient Email: *
Why have you come to the dentist today?
Do you require antibiotics before dental treatment?
Are you currently in pain?
Have you had a serious / difficult problem associatedwith any previous dental work?
Do you have fears about going to the dentist?
Have you ever had gum disease?
Do you now or have you ever experienced pain /discomfort in your jaw joint (TMJ / TMD)?
Your current dental health is:
How many times a week do you brush?
Do you like your smile?
How many times a day do you floss?
Do your gums bleed?
Type of bristles?
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?
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.
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