Patient Dental History Form

Patient Name*

First Last

Date of Birth*

1. When was you last dental exam?*

Where?*

2. When was your last full mouth x-ray taken?*

Where?*

3. Have you had trouble from previous dental care?*

Yes
No

4. Do you have pain in your jaw or near your ears?*

Yes
No

5. Do you have any unhealed injuries or inflamed areas in or around your mouth?*

Yes
No

6. Have you experienced any growths or sore spots in your mouth?*

Yes
No

7. Does any part of your mouth hurt when clenched?*

Yes
No

8. Have you ever had local anesthetic?*

Yes
No

9. Have you ever had Nitrous Oxide (laughing gas)?*

Yes
No

10. Have you ever had general anesthesia?*

Yes
No

11. Have you ever had any reaction or allergic symptoms to local or general anesthetics?*

Yes
No

12. Have you ever had any difficult extractions in the past?*

Yes
No

13. Have you ever had prolonged bleeding following extractions in the past?*

Yes
No

14. Do your gums bleed?*

Yes
No

15. Do you have a bad taste in your mouth or mouth odor?*

Yes
No

16. Have you ever had instructions on the care of your gums?*

Yes
No

17. Do you chew on only one side of you mouth?*

Yes
No

18. Do you habitually clench or grind your teeth during the night or day?*

Yes
No

19. Is any part of you mouth sensitive to pressures or irritants (hot, cold, or sweets)?*

Yes
No

Is there any other problem not covered above that you would like to discuss?

I hereby give my permission to Greenwood Dental Clinic and staff to examine and x-ray my teeth as necessary to determine what dental treatment is necessary for maximum oral health. I also understand that there are certain inherent risks in receiving dental treatment including: possible allergic reactions to anesthetic, prescribed medications or dental materials, infections, instrument failure, as well as the fact that dental medicine is not an exact science and that precise outcome or perfect results cannot be guaranteed.

I Agree*

Yes
No

Thank you! We will have this document printed and ready to sign when you arrive for your first appointment. Click SUBMIT to sent and continue.

Notes: