Aesthetics & Prosthodontics Dentistry, LLC
849 Lincoln Avenue
Glen Rock, NJ 07452
Dental History
Patient Name:
Date:
Chief concern
(reason for coming to the clinic)
:
Date of last dental visit:
Reason for last dental visit:
Name and address of dentist:
1. Please select the word that describes the current condition of your
Teeth:
Poor
Fair
Good
Excellent
Gums:
Poor
Fair
Good
Excellent
2. How important is it to you to save all your teeth?
Very important
Sort of important
Not too important
Don't know
3. Are you unhappy with the appearance of your teeth?
Yes
No
Don't Know
4. Have you had any difficulty with previous dental treatment?
Yes
No
Don't Know
5. Has fear kept you from seeking dental treatment?
Yes
No
Don't Know
6. Do your gums bleed when you brush your teeth?
Yes
No
Don't Know
7. Do you use dental floss?
Yes
No
Don't Know
8. Have you ever been told you had trench mouth or gum disease?
Yes
No
Don't Know
9. Have you ever been treated for gum disease?
Yes
No
Don't Know
10. Do you have halitosis (bad breath) or an unpleasant taste in your mouth?
Yes
No
Don't Know
11. Are there any lumps or bumps in your mouth?
Yes
No
Don't Know
12. Do you have difficulty swallowing?
Yes
No
Don't Know
13. Do you have teeth sensitive to hot, cold, or sweets?
Yes
No
Don't Know
14. Does your food wedge between your teeth?
Yes
No
Don't Know
15. Do you have any loose teeth?
Yes
No
Don't Know
16. Have you ever noticed any of your teeth shifting or space increasing between them?
Yes
No
Don't Know
17. Have you ever had braces on your teeth?
Yes
No
Don't Know
18. Do you hold pens, pencils, pipes, eyeglasses or other such objects between your teeth?
Yes
No
Don't Know
19. Do you have any teeth that are sore or squeak when you chew or put pressure on them?
Yes
No
Don't Know
20. Do you have a habit of grinding or clenching your teeth together?
Yes
No
Don't Know
21. Do you have pain in the area of your ears or jaws?
Yes
No
Don't Know
22. Does your jaw hurt when you open wide or take a big bite?
Yes
No
Don't Know
23. Does your jaw make noise so that is
bothers
you or others?
Yes
No
Don't Know
24. Do you suffer from headaches?
Yes
No
Don't Know
If so, how often:
25. Do you have pain in the face, eyes, neck, or throat?
Yes
No
Don't Know
26. Does the
pain or discomfort disturb your sleep
?
Yes
No
Don't Know
27. Does the
pain or discomfort interfere with your daily routine or other activities
?
Yes
No
Don't Know
28. Do you take
tablets for pain or discomfort
?
Yes
No
Don't Know
29. Do you take
tablets for relaxation
?
(Valium?)
Yes
No
Don't Know
30. Has anyone ever heard you
grinding in your sleep
, or are you aware of it yourself?
Yes
No
Don't Know
31. Are you aware that you
clench or set your teeth
?
Yes
No
Don't Know
32. Do you have any of the following symptoms upon waking in the morning?
A. Stiff Jaw?
Yes
No
Don't Know
B. Sore jaw or teeth?
Yes
No
Don't Know
C. Headache?
Yes
No
Don't Know
D. Cracking or locking of jaw joint?
Yes
No
Don't Know
33. Does your jaw
"feel tired" after a big meal
?
Yes
No
Don't Know
34. Is it more comfortable when you
chew on one side exclusively
?
Yes
No
Don't Know
35. Did you live in a town that had flouridated water when you were a child?
Yes
No
Don't Know
36. Have you ever had fluoride treatment?
Yes
No
Don't Know
37. Do you use a toothpaste with fluoride in it?
Yes
No
Don't Know
38. Do you think that you get a lot of tooth decay?
Yes
No
Don't Know
39. Would you consider your appetite to be:
Good
Fair
Poor
40. What is the total number of
meals
and
snacks
you have on an average day?
41. How many times per day do you eat desserts?
42. How often do you snack between meals?
Never
Seldom
Often
All the time
43. What are typical snack foods for you?
Typical snack foods continued
44. Do you use gum and/or mints, cough drops?
Never
Seldom
Often
All the time
Are these sugarless or regular?
Patient Validation:
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