New Patient Dental History Download Form Dental History Patient Name (required) Birthdate: What is the reason for your visit today ? Are you in pain ? YesNo Date of your last dental visit: What was done then: Previous dentist (name & location): Date of your last full mouth x-rays: Last dental cleaning: How often do you brush your teeth: How often do you floss your teeth: Do you use fluoridated toothpaste? YesNoName: Primary source of drinking water:City WaterBottled WaterWell WaterReverse Osmosis What types of beverages do you typically drink between meals: Do you use tobacco?YesNo Type: Amount: Number of years: How soon after waking do you use tobacco: Previous attempts to quit: YesNo Number of attempts: Do your gums bleed while brushing or flossing: YesNo Are your teeth sensitive to hot or cold liquids/foods: YesNo Are your teeth sensitive to sweet or sour liquids/foods: YesNo Do you feel pain in any of your teeth : YesNo Do you have any sores or lumps in or near your mouth YesNo Have you had any head, neck, or jaw injuries YesNo Have you ever experienced any of the following problems in your jaw? Clicking YesNo Pain (joint, ear, side of face) YesNo Difficulty opening or closing YesNo Difficulty chewing YesNo Do you have frequent headaches YesNo Do you clench or grind your teeth YesNo Do you bite your lips or cheeks frequently YesNo Have you noticed any loosening of your teeth YesNo Does food tend to become caught between your teeth YesNo Have you ever had periodontal treatment (gums) YesNo Have you had orthodontics (braces) YesNo Do you wear denture(s) or partial(s) YesNo Do you like your smile YesNo Would you like to bleach your teeth YesNo If you could change anything about your smile, what would you change ?