Adult Dental History (Single Form) Adult Dental History (Single Form) Step 1 of 3 33% Name First Middle Last Date of Birth Date Format: MM slash DD slash YYYY 1. Purpose of initial visit2. Are you aware of a problem?3. How long since your last dental visit?4. What was done at that time?5. Previous Dentist’s namePrevious Dentist’s AddressPrevious Dentist’s Telephone6. When was the last time your teeth were cleaned?7. Have you made regular visits?YesNoHow often?8. Were dental x-rays taken?YesNo9. Have you lost any teeth or have any teeth been removed?YesNoWhy?10. Have they been replaced?YesNo11. How have they been replaced?Fixed bridgeRemovable bridgeDentureImplant12. Are you unhappy with the replacement?YesNoIf Yes, Please Explain13. Would you like to know about permanent replacements?YesNo14. Have you ever had any problems or complications with previous dental treatment?YesNoIf Yes, explain: 15. Do you clench or grind your teeth?YesNo16. Does your jaw click or pop?YesNo17. Have you experienced any pain or soreness in the muscles or your face or around your ear?YesNo18. Do you have frequent headaches, neckaches or shoulder aches?YesNo19. Does food get caught in your teeth?YesNo20. Are any of your teeth sensitive to:Hot?Cold?Sweets?Pressure?21. Do your gums bleed or hurt?YesNoWhen?22. Do you experience dry mouth?YesNo23. How often do you brush your teeth?YesNoWhen do you brush your teeth?24. Do you use dental floss?YesNoHow often do you use dental floss? 25. Are any of your teeth loose, tipped, shifted or chipped?YesNo26. Are you unhappy with the appearance of your teeth?YesNo27. How do you feel about your teeth in general?28. Do you feel your breath is offensive at times?YesNo29. Have you ever had gum treatment or surgery?YesNoPlease tell us what treatment or surgery, and where and when30. Have you had any orthodontic work?YesNo31.Have you had any unpleasant dental experiences or is there anything about dentistry that you strongly dislike?32. Do you have any questions or concerns?YesNo"I certify that the above information is complete and accurate"* First Last By typing your full name here, you are electronically signing this document.