Dental History

Please fill out the form below

Patient Information

First Name *

Last Name *

Middle Initial

Email *

Phone

How May We Help You Today?

Hygiene Habits

How Many Times Do You Floss Per Week?

How Many Times Do You Brush Per Day?

Clinical Questions

Your Current Dental Health Is:

Good Fair Poor

Require Antibiotics Before Dental Treatment?

Yes No

Are You Currently In Pain?

Yes No

Have You Ever Had Gum Treatment?

Yes No

Do You Now Or Have You Had Any Pain/Discomfort In Your Jaw Joint?

Yes No

Are You Under Stress? (New Job, Moving, Relationships, etc.)

Yes No

Do You Like Your Smile?

Yes No

Is There Anything You Would Like To Change About Your Smile?

Yes No

Are You Happy With The Color Of Your Teeth?

Yes No

Do Your Gums Bleed?

Yes No

Are Your Teeth Sensitive To Heat, Cold Or Anything Else?

Yes No

Have You Lost Any Teeth?

Yes No

Have You Ever Had A Difficult Problem With Any Previous Dental Work?

Yes No

Have You Ever Had Any Unfavorable Dental Experiences?

Yes No

Visit History

When Was Your Last Dental Cleaning?

When Was Your Last Dental Visit?

Why Did You Leave Your Previous Dentist?

How Can We Accommodate You Better During Your Dental Visit?

Nova Dental Studio

Address

Michael J. Paesani, DMD – NOVA Dental Studio
200 Little Falls St #101
Falls Church, VA 22046

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Contact Us

info@novadentalstudio.com

(703) 237-7725

2026 Nova Dental Care copyright all. right reserved

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