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Mark L Davies, DDS, FAGD
1664 Village Green • Crofton, MD 21114 • (301) 261-3800 • (410) 721-8688
www.drmarkdavies.com
Dental History Form
Name
Date:
Reason for today's visit
Former Dentist
City/State
Date of Last Dental vist
Date of last dental X-rays
Place a mark on "yes" or "no" to indicate if you have had any of the following:
Bad Breath
Y
N
Bleeding Gums
Y
N
Blisters on lips or mouth
Y
N
Burning sensation on tongue
Y
N
Chew on one side of mouth
Y
N
Cigarette, pipe or cigar smoking
Y
N
Clicking or popping jaw
Y
N
Dry mouth
Y
N
Fingernail biting
Y
N
Food collection between the teeth
Y
N
Foreign objects
Y
N
Grinding Teeth or clenching
Y
N
Gums swollen or tender
Y
N
Jaw pain or tiredness
Y
N
Lip or cheek biting
Y
N
Loose teeth or broken filings
Y
N
Mouth breathing
Y
N
Mouth pain, brushing
Y
N
Orthodontic Treatment
Y
N
Pain around ear
Y
N
Periodontal Treatment
Y
N
Sensitivity to cold
Y
N
Sensitivity to heat
Y
N
Sensitivity to sweets
Y
N
Sensitivity when biting
Y
N
Sores or growths in your mouth
Y
N
How often do you floss?
How often do you brush?
When was your last set of full mouth radiographs? -
18 individual x-rays or panorex film (large film that shows all your teeth)
How often do you get your teeth cleaned?
Have you had serious trouble with any previous dental treatment?
Y
N
If yes, please explain
What did you like the most about your previous dental office?
What did you like the least about your previous dental office?
Do you wear night guard?
Appliance?
Removable denture?
If you have missing teeth, what was the cause? (decay, gum disease, trauma)
How important is it to retain your teeth all of your life?
What toothpaste do you use?
Frequency?
What mouth rinse do you use?
Frequency?
Have you ever had teeth removed?
If so, was a local anesthetic
(needle)
used or was general anesthesia
(put to sleep)
used?
Which do you prefer?
If you have had teeth removed, has it ever been recommended to replace them?
Do you want all the details about necessary treatment or just an overview?
Are you satisfied with the appearance of your teeth, gums, and your smile?
Y
N
Would you like to discuss enhancing the appearance of your smile?
Y
N
Would you like to discuss how to make your teeth white(r)?
Do you have old fillings or other dental work that you aren't happy with that you want to replace?
Does your jaw get stuck, locked or go out?
Y
N
Has your jaw, head, or neck ever been injured?
Y
N
Have you ever been treated for a TMJ problem?
Y
N
If yes, please check the following that apply:
Bite Splint
Medication
Surgery
Orthodontics
Physical Therapy
Equilibration
Counseling
What are your short, medium, and long term goals for your mouth and teeth?
Short
Medium
Long
Please check the #1 barrier you have to dental care:
Money
Time
Pain
Fear (of what?)
Examples are: needles, noise, smell, invasion of personal space.
Patient Validation:
Submit Form
Clear Signature
Accept Signature
X
