Aesthetics & Prosthodontics Dentistry, LLC
849 Lincoln Avenue
Glen Rock, NJ 07452

Dental History

1. Please select the word that describes the current condition of your
2. How important is it to you to save all your teeth?
3. Are you unhappy with the appearance of your teeth?
4. Have you had any difficulty with previous dental treatment?
5. Has fear kept you from seeking dental treatment?
6. Do your gums bleed when you brush your teeth?
7. Do you use dental floss?
8. Have you ever been told you had trench mouth or gum disease?
9. Have you ever been treated for gum disease?
10. Do you have halitosis (bad breath) or an unpleasant taste in your mouth?
11. Are there any lumps or bumps in your mouth?
12. Do you have difficulty swallowing?
13. Do you have teeth sensitive to hot, cold, or sweets?
14. Does your food wedge between your teeth?
15. Do you have any loose teeth?
16. Have you ever noticed any of your teeth shifting or space increasing between them?
17. Have you ever had braces on your teeth?
18. Do you hold pens, pencils, pipes, eyeglasses or other such objects between your teeth?
19. Do you have any teeth that are sore or squeak when you chew or put pressure on them?
20. Do you have a habit of grinding or clenching your teeth together?
21. Do you have pain in the area of your ears or jaws?
22. Does your jaw hurt when you open wide or take a big bite?
23. Does your jaw make noise so that is bothers you or others?
24. Do you suffer from headaches?
25. Do you have pain in the face, eyes, neck, or throat?
26. Does the pain or discomfort disturb your sleep?
27. Does the pain or discomfort interfere with your daily routine or other activities?
28. Do you take tablets for pain or discomfort?
29. Do you take tablets for relaxation? (Valium?)
30. Has anyone ever heard you grinding in your sleep, or are you aware of it yourself?
31. Are you aware that you clench or set your teeth?
32. Do you have any of the following symptoms upon waking in the morning?
A. Stiff Jaw?
B. Sore jaw or teeth?
C. Headache?
D. Cracking or locking of jaw joint?
33. Does your jaw "feel tired" after a big meal?
34. Is it more comfortable when you chew on one side exclusively?
35. Did you live in a town that had flouridated water when you were a child?
36. Have you ever had fluoride treatment?
37. Do you use a toothpaste with fluoride in it?
38. Do you think that you get a lot of tooth decay?
39. Would you consider your appetite to be:
42. How often do you snack between meals?
44. Do you use gum and/or mints, cough drops?