Adult Dental History (Single Form) Step 1 of 3 33% Name First Middle Last Date of Birth MM slash DD slash YYYY 1. Purpose of initial visit 2. 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 name Previous Dentist’s Address Previous Dentist’s Telephone 6. When was the last time your teeth were cleaned? 7. Have you made regular visits? Yes No How often? 8. Were dental x-rays taken? Yes No 9. Have you lost any teeth or have any teeth been removed? Yes No Why? 10. Have they been replaced? Yes No 11. How have they been replaced? Fixed bridge Removable bridge Denture Implant 12. Are you unhappy with the replacement? Yes No If Yes, Please Explain 13. Would you like to know about permanent replacements? Yes No 14. Have you ever had any problems or complications with previous dental treatment? Yes No If Yes, explain: 15. Do you clench or grind your teeth? Yes No 16. Does your jaw click or pop? Yes No 17. Have you experienced any pain or soreness in the muscles or your face or around your ear? Yes No 18. Do you have frequent headaches, neckaches or shoulder aches? Yes No 19. Does food get caught in your teeth? Yes No 20. Are any of your teeth sensitive to:Hot?Cold?Sweets?Pressure?21. Do your gums bleed or hurt? Yes No When? 22. Do you experience dry mouth? Yes No 23. How often do you brush your teeth? Yes No When do you brush your teeth? 24. Do you use dental floss? Yes No How often do you use dental floss? 25. Are any of your teeth loose, tipped, shifted or chipped? Yes No 26. Are you unhappy with the appearance of your teeth? Yes No 27. How do you feel about your teeth in general? 28. Do you feel your breath is offensive at times? Yes No 29. Have you ever had gum treatment or surgery? Yes No Please tell us what treatment or surgery, and where and when 30. Have you had any orthodontic work? Yes No 31.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? Yes No "I certify that the above information is complete and accurate"(Required) First Last By typing your full name here, you are electronically signing this document.