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(760) 230-0060
285 N El Camino Real Suite #112, Encinitas, CA
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Home
About Us
Meet The Doctor
Services
Patients
Patient Forms
Patient Information Form
Patient Hisotry Form
Insurance
Financial
Smile Gallery
Membership
Blog
Contact Us
Book An Appointment
Dental History Form
Patient Name
(Required)
Email
(Required)
Cell Number
Reason for today’s visit
How often do you routinely see the dentist?
3 Months
4 Months
6 Months
Not routinely
Please rate your anxiety / Fear of dental treatment:
0
1-3
4-6
7-9
10+
How you had an unfavorable dental experience?
Yes
No
Ever had complications with past dental treatment?
Yes
No
Ever had trouble getting numb or had any reaction to anesthetic?
Yes
No
Do you have an immediate dental concern?
Yes
No
If yes Please Answer
Bite and Jaw Joint
Do you have any problems with your jaw joint? (Pain, sounds, limited opening, locking, popping)
Yes
No
Do you have any problems chewing bagels, protein bars, or other hard foods?
Yes
No
Do you have any problems chewing bagels, protein bars, or other hard foods?
Yes
No
Are your teeth crowding or developing spaces?
Yes
No
Do you have any problems chewing bagels, protein bars, or other hard foods?
Yes
No
Do you have any problems chewing bagels, protein bars, or other hard foods?
Yes
No
Do you have more than one bite and squeeze to make your teeth fit together?
Yes
No
Have you ever worn a bite appliance?
Yes
No
Do you have any problems with sleep, or wake up with an awareness of your teeth or jaw?
Yes
No
Tooth Structure
Have you had any cavities in the last 3 years?
Yes
No
Does your mouth feel dry or do you have difficulty swallowing food?
Yes
No
Do you feel or notice any holes, pits, or craters in your teeth?
Yes
No
Are your teeth sensitive to hot, cold, biting, or sweets?
Yes
No
Do you avoid brushing any part of your mouth?
Yes
No
Do you have grooves or notches on your teeth near the gum line?
Yes
No
Do you frequently get food caught between your teeth?
Yes
No
Smile Characteristics
Is there anything about the appearance of your teeth you would like to change?
Yes
No
Would you like your teeth whiter?
Yes
No
Have you felt uncomfortable or self-conscious about the appearance of your teeth?
Yes
No
Have you been disappointed with the appearance of previous dental work?
Yes
No
Gum and Bone
Do your gums bleed or are they painful when you brush or floss?
Yes
No
Have you ever been treated for gum disease or told you have lost bone?
Yes
No
Have you ever noticed an unpleasant taste or odor in your mouth?
Yes
No
Is there anyone in your family with a history of periodontal disease?
Yes
No
Have you ever experienced gum recession?
Yes
No
Have you ever had teeth become loose (without injury) or have difficulty eating?
Yes
No
Have you ever had a burning sensation in your mouth?
Yes
No
