Dental History (Adult) Name* First Last Why are you changing your dentist?How long ago was your last visit to your dentist?*Name of previous dentistHow did you find us?Reason for Today's Visit Check-Up Cleaning Pain Other OtherHave you ever had a bad experience at the dentist?*YesNoHave you had any complications following treatment?*YesNoHave you had any unfavorable reactions to dental anesthetic?*YesNoDoes dental treatment make you nervous?*Are your teeth sensitive to cold or hot temperatures?*YesNoDo your gums bleed when you brush or floss?*YesNoDo you grind your teeth?*YesNoAre you aware of sores or irritated areas in the mouth?*YesNoHave you ever been treated for Periodontal Disease?*YesNoHow often do you brush?*How often do you floss?*Do you like your smile?*YesNoIf you could change your smile, what would you like to change? Change the color of my teeth Close spaces or restore worn out or broken teeth Change the shape of my teeth Change the position or alignment of my teeth Other OtherI am interested in Teeth whitening Cosmetic evaluation Replacement of missing teeth Straight teeth Sedation White fillings Home care Breath control Other OtherTo ensure your visit is a great experience, please share any questions or concerns you would like us to know about:Signature*Relationship to The PatientName If Not the Patient
