201 East Chestnut Street • Asheville, NC 28801 • 828.252.7304 • Contact Us
Medical & Dental History

Submit the form below or download and fill out the PDF version and take it with you to your appointment.

DENTAL HISTORY

Referred by

Previous dentist How long

Most recent dental exam

Most recent dental x-ray

Most recent dental treatment

How often do you have your teeth cleaned? 3 mo. 4 mo. 6 mo. 1 year or longer

WHAT IS YOUR IMMEDIATE DENTAL CONCERN?

PLEASE ANSWER YES OR NO TO THE FOLLOWING: NO YES

  1. Unhappy with the appearance of your teeth
  2. Unfavorable dental experiences
  3. Dental fears
  4. Problems with effectiveness or bad reactions to dental anesthetic
  5. Orthodontic treatment (braces) when
  6. Periodontal (gum) treatment when
  7. Bleeding gums
  8. Avoid brushing any part of your mouth
  9. Part of your mouth is sensitive to temperature
  10. Sore teeth
  11. A burning sensation in your mouth
  12. Difficulty swallowing
  13. An unpleasant taste or odor in your mouth
  14. Dry mouth, throat, and or eyes
  15. Jaw problems (temporomandibular joint)
  16. Difficulty opening your mouth widely
  17. Stiff neck muscles
  18. Awaken with an awareness of your teeth or jaws
  19. Tension headaches
  20. Clench or grind your teeth
  21. Jaw clicking or popping
  22. Lost any teeth
  23. Do you sweat or tremble a lot during examination
  24. Do strange people or places make you afraid

SUPPLEMENTAL DENTURE HISTORY

If you are wearing a partial or complete artifical denture, please complete the following:

YES NO

Has your present denture been relined? When

Is your present denture a problem? Describe

Satisfied with the appearance?

Satisfied with the comfort?

Satisfied with the chewing ability?

When did you receive your first partial or complete denture?

How long have you worn your present denture?


Patient's Signature Date

Doctor's remarks Doctor's signature





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