Western New York Dental Group Forms Portal
Western New York Dental Group Forms Portal
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Dental History
Please answer the following items as completely as possible. Please complete all sections that apply. Click the 'Submit' button at the bottom of the form when you are finished. Thank you!
Dental History
Last Name:
*
First Name:
*
Home Phone:
Reason for your visit?
Previous Dentist's Name:
Previous Dentist's Address:
How often do you...
Brush your teeth?
Floss your teeth?
Have dental exams?
What was the date of your last...
Visit?
Hygiene visit?
X-Ray?
What other oral hygiene
aids do you use
(electric toothbrush, etc.)?
Do you have
any dental problems?
Yes
No
If yes, explain:
Personal History
Have you ever
had orthodontic treatment?
Yes
No
Have you ever
had oral surgery?
Yes
No
Have you ever
had any teeth removed?
Yes
No
If so, have
they been replaced?
Yes
No
Have you ever
had a fixed bridge?
Yes
No
Have you ever
had removable partial?
Yes
No
Have you ever
had a complete denture?
Yes
No
Have you ever
had implants?
Yes
No
If so, are you
happy with the replacements?
Yes
No
Have you ever
had periodontal treatment?
Yes
No
Have you ever
had gum surgery?
Yes
No
If so, when?
By whom?
Have you ever
had your teeth ground
or bite adjusted?
Yes
No
Have you ever
had a serious injury
to the mouth or head?
Yes
No
If so, please
describe (include cause):
Do you feel
anxiety about having
dental treatment?
Yes
No
How did you
overcome your anxiety?
Have you ever
had an upsetting
dental experience?
Yes
No
If yes, please describe:
Smile Characteristics
Do you like the
appearance of your
teeth and smile?
Yes
No
Do you like the
color of your teeth?
Yes
No
Would you like
your teeth straightened?
Yes
No
What would you like
to change most in the
appearance of your teeth?
Tooth Structure
Are any of your
teeth sensitive to
hot or cold
liquids/foods?
Yes
No
Are any of your
teeth sensitive to
sweet or sour
liquids/foods?
Yes
No
Are any of your
teeth sensitive to
biting or pressure?
Yes
No
Have you noticed
any loose teeth
or change in your bite?
Yes
No
Do you get food
caught between
your teeth?
Yes
No
Gum and Bone
Have you ever
noticed any mouth
odors or bad taste?
Yes
No
Do you frequently
get cold sores,
blisters, or any lesions?
Yes
No
Do your gums
bleed or hurt?
Yes
No
Have your parents
experienced gum disease
or tooth loss?
Yes
No
Bite and Jaw Joint
Do you clench or grind
teeth (awake or asleep)?
Yes
No
Do you have tired jaws
(especially in the morning)?
Yes
No
Do you bite your
lips or cheeks regularly?
Yes
No
Do you hold foreign objects
with your teeth(pencils,
pens, nails, fingernails, pipe)?
Yes
No
Do you mouth breathe while
asleep or awake?
Yes
No
Do you snore?
Yes
No
Have you ever
experienced clicking
or popping of the jaw?
Yes
No
Have you ever
experienced pain
(joint, ear or side of face)
Yes
No
Have you ever
experienced difficulty opening
or closing the mouth?
Yes
No
Have you ever
experienced frequent
headaches, neck aches,
or shoulder aches?
Yes
No
Have you ever
experienced any pain
or soreness in the
muscles of your face
or around the ears?
Yes
No
Is there anything else about having dental treatment
that you would like to let us know?
By submitting this form, I consent to the doctor's exam
and necessary diagnostics for treatment, including x-rays.
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