Dental History Form

DENTAL HISTORY

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  PATIENT DENTAL HISTORY   

PERSONAL HISTORY

Excellent
Good
Fair
Poor
Every 3 Months
Every 4 Months
Every 6 Months
Every 12 Months
Not Routinely
Yes
No
Yes
No
Yes
No
Yes
No


SMILE CHARACTERISTICS

Yes
No
Yes
No
Yes
No
Yes
No


BITE AND JAW JOINT

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No


TOOTH STRUCTURE

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No


GUM AND BONE

Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
You
No
Yes
No


I HAVE READ AND AGREE with my electronic signature that I had opportunity to review this document prior to signing it.

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