DENTALBRERACLINIC • Dental History SheetPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Surname and Name (maiden name) *Married surname *Date of birth *Place of birth *How often do you typically go to the dentist? *6 months or less1 year or moreonly in case of necessityWhen was your last visit to the dentist? *When was the last X-ray? *How many times a day do you brush your teeth? *three or moretwooneDo you floss regularly? *YesNoDo you use any mouthwash? *YesNoIf so, what mouthwash do you use?PAST EXPERIENCESAre you worried about dental treatment? *YesNoOn a scale of 1 (a little) to 10 (a lot)? *12345678910Have you ever had any negative experiences or complications with dental treatments you received? *YesNoHave you ever had problems being anesthetized or had any reactions to the anesthetic? *YesNoHave you ever undergone orthodontic treatment with fixed or removable appliances? *YesNoHave you ever undergone occlusal adjustments (grinding or tooth retouching)? *YesNoHave you had any teeth pulled? *YesNoTHE SMILEIs there anything about the appearance of your teeth that you would like to change?Have you ever whitened your teeth? *YesNoDo you ever feel uncomfortable about your teeth?YesNoHave you ever been disappointed by the appearance of dentures made for you in the past?YesNoCHEWING AND JOINTSDo you have trouble chewing gum? *YesNoDo you have trouble chewing tough or hard foods? *SiNouse? your dental Have your teeth changed in the last 5 years, become shorter, thinner, or worn down? *YesNoHave your teeth shifted, overlapped, or developed spaces? *YesNoDoes he have more than one position where he clenches his teeth together or clenches his teeth together? *YesNoDoes he bite his nails, chew ice cubes, use his teeth to hold objects, or have other bad habits? *YesNoDo you grind or clench your teeth at night or during the day? *YesNoDo you have trouble sleeping or wake up aware of your teeth? *YesNoDo you have problems with your temporomandibular joints (pain in front of or behind the ear, noises in the ear area, limited mouth opening, locking of the joint)? *YesNoDo you suffer from headaches, neck pain or are your teeth sore? *YesNoDo you wear or have you worn a night guard or mouth guard? *YesNoTHE TEETHHave you had cavities in the last 3 years? *YesNoDoes your mouth tend to be dry or do you have difficulty swallowing food? *YesNoAre your teeth sensitive to cold, heat, pressure, or sweet foods, or do you avoid brushing your teeth? *YesNoHave you ever had a toothache, a fractured filling, a chipped or broken tooth? *YesNoDoes food ever get stuck between your teeth? *YesNoGUMS, MUCOUS MEMBRANES AND BONEWhen you brush or floss, do your gums bleed? *YesNoHave you ever had receding gums? *YesNoHave your teeth become loose (not due to trauma) or do you have difficulty biting into an apple? *YesNoHave you ever noticed sores, swellings, or spots inside your mouth? *YesNoDo you suffer from bad breath or have you ever had a bad taste in your mouth? *YesNoDo you have a burning sensation in your mouth? *YesNoHave you ever been diagnosed with periodontal disease (pyorrhea) or treated for it? *YesNoIs there anyone in your family who has been diagnosed with periodontal disease (pyorrhea)? *YesNoDo you have any other information to report? *YesNoIf so, which ones?I certify that I have read and understood the questionnaire I am signing and that the above information is true and accurate. I therefore authorize the healthcare professionals at this facility to use it confidentially in order to provide me with the most appropriate care possible. I also undertake to promptly communicate any changes in my health status.I authorize *YesNoDate *Send
