Dental History

Please fill out the form below

    First Name

    Last Name

    Email

    Phone

    How May We Help You Today?

    How Many Times Do You Floss Per Week?

    How Many Times Do You Brush Per Day?

    Your Current Dental Health Is:
    GoodFairPoor

    Require Antibiotics Before Dental Treatment?
    YesNo

    Are You Currently In Pain?
    YesNo

    Have You Ever Had Gum Treatment?
    YesNo

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

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

    Do You Like Your Smile?
    YesNo

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

    Are You Happy With The Color Of Your Teeth?
    YesNo

    Do Your Gums Bleed?
    YesNo

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

    Have You Lost Any Teeth?
    YesNo

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

    Have You Ever Had Any Unfavorable Dental Experiences?
    YesNo

    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?