Text Box: Dental History Why Have You Come To The Dentist Today? ______________________________________________________ ______________________________________________________________________________________________ Are You Currently In Pain __Yes __No Are Your Teeth Sensitive __Yes __No If Yes, __Hot __Cold __Pressure __Chewing Do Your Gums Ever Bleed? __Yes __No Have You Ever Had Periodontal Disease? __Yes __No Do You Have Mobility In Your Teeth? __Yes __No Do You Require Antibiotics Before Dental Treatment? __Yes __No Do You Prefer To Be Sedated For Dental Treatment? __Yes __No If Yes, __Nitrous Oxide __Valium __IV Sedation Have You Had Any Head, Neck, Or Jaw Injuries? __Yes __No Do You Clinch Or Grind Your Teeth __Yes __No Is Your Bite Uncomfortable When Chewing or Biting? __Yes __No Do You Experience Pain In Your Jaw Joints (TMJ)? __Yes __No If Yes, __AM __PM Do Your Jaw Muscles Hurt? __Yes __No If Yes, __AM __PM Do You Smoke? __Yes __ No If Yes, How much? _______________ Previous Dentist: _______________________________ Why Did You Leave Your Previous Dentist? ____________________________________________________________ What Did You Like The Most About Your Previous Dentist?________________________________________________ What Did You Like The Least About Your Previous Dentist? _______________________________________________ Smile Assessment Are You Concerned With The Appearance of Your Teeth or of Your Smile? __Yes __No Are You Concerned About The Whiteness or Lack of Whiteness of One Or More of Your Teeth? __Yes __No Are You Concerned About The Position or Angle of One or More of Your Teeth? __Yes __No Are You Concerned About The Shape of One or More of Your Teeth? __Yes __No In Social Situations, Are You Sometimes Embarrassed By Your Teeth or Your Smile? __Yes __No Do You Have Old Fillings or Existing Dental Treatment That Is No Longer Satisfactory To You? __Yes __No Are You Interested In Learning More About Esthetic or Cosmetic Dentistry? __Yes __No Please List Any Other Problems, Concerns, or Questions: __________________________________________________ _______________________________________________________________________________________________