Dental History

Dental History Jefferson M. Sims, DMD PA
As with all forms and information you provide, your entries are for our records only, and will be considered confidential. Additionally, any discussions regarding the entries on this form will be held in the strictest confidence.
Today’s Date:
First and Last Name:
Day Time Phone
Email Address:
Date of birth:
Please describe your current dental concerns:
Date (approximate is OK) of your last dental visit:
Name of your last dentist (optional):
Location of your last dentist (town or city):
Reason for changing dentists (optional):
Are you satisfied with the appearance of your teeth?	Yes No
If “No”, what changes would you like?
Are you missing any teeth?	Yes No
If “Yes”, have they been replaced?	Yes No
Are any teeth discolored, stained, or crooked?	Yes No
If “Yes”, does this bother you?	Yes No
Are there any fillings or blemishes that look bad to you?	Yes No
Have you ever had any “cosmetic” dentistry done?	Yes No
If “Yes”, please describe the treatment:
Are you currently satisfied with the “cosmetic” treatment?	Yes No
Would you like for your teeth to be whiter?	Yes No
Has any professional whitening been attempted?	Yes No
Has any over-the-counter whitening been attempted?	Yes No
Are any of your teeth sensitive to the following (check all that apply):	Hot Cold Pressure Sweets none
Does food ever wedge between certain teeth?	Yes No
Do you have any areas that are difficult to floss?	Yes No
Has any gum tissue dropped away (receded), exposing more tooth?	Yes No
Do your gums bleed when you brush or floss?	Yes No
Do you feel that you have unpleasant breath?	Yes No
Do you have any unpleasant taste sensations?	Yes No
Have you ever been treated by a periodontist (gum specialist)?	Yes No
If “Yes”, please describe the treatment:
Have you ever had orthodontic treatment (braces, etc.)	Yes No
Have you ever had any gum treatment in a general dental office?	Yes No
If “Yes”, please describe the treatment
Have your third molars (“wisdom teeth”) been removed?	Yes No
If “Yes”, when was this treatment done?
If “No”, are you having any problems with your third molars?
Are you wearing any removable dental prostheses (partial or full dentures)?	Yes No
Do you have any difficulty chewing your food?	Yes No
Do you have any difficulty pronouncing certain words?	Yes No
Are there any areas in your mouth where you can’t chew?	Yes No
Do you have any history of stomach ulcers, heartburn, or G.E.R.D.?	Yes No
(Optional) Do you have any history of eating disorders?	Yes No
If “Yes”, is this something you’d like to discuss?	Yes No
Do you feel any anxiety regarding dental treatment?	Yes No
Have you ever had any unpleasant dental experiences?	Yes No
Do you feel you need any help overcoming anxiety?	Yes No
Have you ever been administered any of the following for dental treatment (check all that apply):	Nitrous Oxide (“laughing gas”) Intravenous Sedation (needle inserted in arm or hand) Oral Sedation (Valium or other pill) None
If any of the above were used, did you find the sedation helpful?	Yes No
Does your jaw ever make popping, cracking, or grinding sounds?	Yes No
Do your facial muscles or your jaw ever get tired or sore?	Yes No
If “Yes”, under what circumstances?
Do you clench or grind your teeth?	I don't know Yes No
If “Yes”, does this occur while awake, asleep or don't know (check all that apply):	While Awake While Asleep Both I Don’t Know
Has your jaw ever locked open or locked closed?	Yes No
Do you have any problems with Snoring or Sleep Apnea?	Yes No
Is there any information that you’d like to add?
Please click the "submit" button before you go to the next page. You've completed the Dental History form; please fill out the Medical History after you submit this form. Thank you for your time and patience. "There is no such thing as ‘too much information’!"