Dental Health History

Dental health history
YesNo
Are you apprehensive about dental treatment?
Have you had problems with previous dental treatment?
Do you gag easily?
Do you wear dentures?
Does food catch between your teeth?
Do you have difficulty in chewing your food?
Do you chew on only one side of your mouth?
Do you avoid brushing any part of your mouth because of pain?
Do your gums bleed easily?
Do your gums bleed when you floss?
Do your gums feel swollen or tender?
Have you ever noticed slow-healing sores in or about your mouth?
Are your teeth sensitive?
Do you take fluoride supplements?
Are you dissatisfied with the apperance of your teeth?
Do you prefer to save your teeth?
Do you want complete dental care?
YesNo
Does your jaw make noise so that it bothers you or others?
Do you clench or grind your jaws frequently?
Do your jaws ever feel tired?
Does your jaw get stuck so that you can't open freely?
Does it hurt when you chew or open wide to take a bite?
Do you have earaches or pain in front of the ears?
Do you have any jaw symptoms or headaches upon awaking in the morning?
Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities?
Do you find jaw pain or discomfort extremely frustrating or depressing?
Do you take medications or pills for pain or discomfort(pain relievers, muscle relaxants, antidepressants)?
Do you have a temporomandibular (jaw) disorder (TMD, TMJ)?
Do you have pain in te face, cheeks, jaws, joints, throat, or temples?
Are you unable to open your mouth as far as you want?
Are you aware of an uncomfortable bite?
Have you have a blow to the jaw (trauma)?
Are you a habitual gum chewer or pipe smoker?
YesNo
Hot food or liquids?
Cold food or liquids?
Sours?
Sweets?