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Pediatric Dentistry - Coming Soon
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Morris Location
(332) 290-2606
Eastchester Location
(332) 290-1588
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Specials
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Contact
Home
Dr.Gandhi
Invisalign
Financing
Cherry
Care Credit
Services
Emergency Dental Care
Botox & Fillers Bronx NY
Dental Implants
Cosmetic Veneers
Clear Aligner Therapy
Hollywood Smiles
Gum Disease
Laser Bacterial Decontamination
Oral Rehabilitation – Bone Grafting Procedure
Oral Health Check Up
Root Canal Therapy
Specials
Locations
Gallery
Contact
Make Appointment
Dental History
Patient Name
Nickname
Age
Referred by
Previous Dentist (Month, Year)
How would you rate the condition of your mouth?
Excellent
Good
Fair
Poor
Date of most recent x-rays
Date of most recent dental exam
Date of most recent treatment (other than a cleaning)
I routinely see my dentist every
3 mo.
4 mo.
6 mo.
12 mo.
Not routinely
WHAT IS YOUR IMMEDIATE CONCERN?
Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)
Have you had an unfavorable dental experience?
yes
no
Have you ever had complications from past dental treatment?
yes
no
Have you ever had trouble getting numb or had any reactions to local anesthetic?
yes
no
Did you ever have braces, orthodontic treatment or had your bite adjusted, and at what age?
yes
no
Have you had any teeth removed, missing teeth that never developed, or lost teeth due to injury or facial trauma?
yes
no
Do your gums bleed sometimes or are they ever uncomfortable when brushing or flossing?
yes
no
Have you ever had or been told you have gum loss, gum disease, or bone loss between your teeth?
yes
no
Have you ever noticed an unpleasant taste, odor in your mouth, or swollen and puffy gums?
yes
no
Is there anyone with a history of periodontal disease in your family?
yes
no
Have you ever experienced gum recession, or can you see more of the roots of your teeth?
yes
no
Have you ever had any teeth become loose on their own (without an injury), or feel them move when chewing?
yes
no
Have you experienced a burning, painful sensation, or metallic taste in your mouth?
yes
no
Have you had any cavities within the past 3 years?
yes
no
Does the amount of saliva in your mouth seem too little, not enough, or do you have difficulty swallowing or chewing any food?
yes
no
Do you feel or notice any holes (i.e., pitting, craters) on the biting surface of your teeth?
yes
no
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
yes
no
Do you have grooves or notches on your teeth near the gum line?
yes
no
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
yes
no
Do you frequently get food caught between any teeth?
yes
no
Does your jaw joint ever have pain, sounds (popping, cracking), or experience limited opening or locking?
yes
no
Do you feel like you need to pull your lower jaw back, or feel that it is being pushed back when you try to bite your back teeth together?
yes
no
Do you avoid or have difficulty chewing gum, raw carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
yes
no
In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?
yes
no
Are your teeth becoming more crooked, crowded, or overlapped?
yes
no
Are your teeth developing spaces or becoming more loose?
yes
no
Do you have more than one bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together better?
yes
no
Do you place your tongue between your teeth or close your teeth against your tongue?
yes
no
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
yes
no
Do you clench or grind your teeth together in the daytime / nighttime or ever make them sore?
yes
no
Do you have any problems with sleep (i.e., restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
yes
no
Do you wear or have you ever worn a bite appliance?
yes
no
Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change (color, spaces, size, shape, display)?
yes
no
Have you ever bleached (whitened) your teeth?
yes
no
Have you felt uncomfortable or self-conscious about the appearance of your teeth?
yes
no
Have you been disappointed with the appearance of previous dental work?Have you felt uncomfortable or self-conscious about the appearance of your teeth?
yes
no
Patient Signature ( Full Name )
Date
Doctor's Signature ( Full Name )
Date
Send
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