Dental Health History Patient Name_______________________________________ What is the reason for your visit today? __________________ Date of last dental visit___________ Previous Dentist’s name________________________ (HIPPA regulations require that you contact your previous Dentist to release your x-rays) How often do you brush your teeth? ________Floss? ______ How often do you have dental exams/cleanings? _________ What other dental aids do you use? (electric toothbrush, etc.) Do you have any dental problems now? ___Yes ____No If yes, please describe: ________________________________ Please circle below if you have any of the following conditions: Sensitive teeth to hot, cold, sweets                         Headaches Sensitive to biting or chewing                                  Pain in jaw/ear area Bad taste or mouth odors                                       Clicking in jaw area         Cold sores or blisters                                              Mouth injury Gums that bleed or hurt                                          Use a mouth guard Loose teeth                                                             Sleep apnea/snoring         Change in your bite                                                 Sore/tired jaws Food gets caught in teeth                                       Bite lips or cheeks Hold foreign objects with you teeth                         Clench or grind teeth Previous orthodontic treatments                             Chew tobacco Previous oral surgery/extractions                            Smoke Previous periodontal treatment                               Alcoholic drinks Are you satisfied with your teeth’s appearance? __Yes __No Do you feel nervous about dental treatment? __Yes __No If so, what is your biggest concern?  _____________________ Have you had any unpleasant dental experiences? __Yes__No If yes, please describe________________________________ All information is confidential. We will provide you with the best care possible. Let us know if you have any other concerns not listed.