New Patient Forms

Your Dental History

Patient Name

Nickname

Age

Referred by

Previous Dentist

How long have you been a patient?

How would you rate the condition of your mouth?

Excellent Good Fair Poor

Date of most recent dental exam

Date of most recent x-rays

Date of most recent treatment (other than cleaning)

What is your immediate need or concern?

1. Are you fearful of dental treatment?

Yes No

How fearful, on a scale of 1 (least) to 10 (most)

2. Have you had an unfavorable dental experience?

Yes No

3. Have you ever had complications from past dental treatment?

Yes No

4. Have you ever had trouble getting numb or had any reactions to local anesthetic?

Yes No

5. Have you ever had braces, orthodontic treatment or your bite adjusted?

Yes No

6. Have you had any teeth removed?

Yes No

7. Is there anything about the appearance of your teeth that you would like to change?

Yes No

8. Have you ever whitened (bleached) your teeth?

Yes No

9. Have you felt uncomfortable or self conscious about the appearance of your teeth?

Yes No

10. Have you been disappointed with the appearance of previous dental work?

Yes No

11. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

Yes No

12. Do you / would you have any problems chewing gum?

Yes No

13. Do you / would you have any problems chewing bagels, baguettes, protein bars, or other hard foods?

Yes No

14. Have your teeth changed in the last 5 years, become shorter, thinner or worn?

Yes No

15. Are your teeth crowding or developing spaces?

Yes No

16. Do you have to squeeze to make your teeth fit together or do you have more than one bite?

Yes No

17. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?

Yes No

18. Do you clench your teeth in the daytime or make them sore?

Yes No

19. Do you have any problems with sleep or wake up with an awareness of your teeth?

Yes No

21. Have you had any cavities within the past 3 years?

Yes No

22. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

Yes No

23. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?

Yes No

24. Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?

Yes No

25. Do you have grooves or notches on your teeth near the gum line?

Yes No

26. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?

Yes No

27. Do you get food caught between any teeth?

Yes No

28. Do your gums bleed when brushing or flossing?

Yes No

29. Have you ever been treated for gum disease or been told you have lost bone around your teeth?

Yes No

30. Have you ever noticed an unpleasant taste or odor in your mouth?

Yes No

31. Is there anyone with a history of periodontal disease in your family?

Yes No

32. Have you ever experienced gum recession?

Yes No

33. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple?

Yes No

34. Have you experienced a burning sensation in your mouth?

Yes No

Type your full name (by typing your full name you agree to submit this as a digital signature)

Today's Date

Prefer to fill out a PDF to bring in?

3502 Bay to Bay Blvd. Tampa, Florida 33629 | 813-839-6999