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601 Front Street, Nelson, B.C.
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Dental History Form
Patient Information
Patients Name
*
Date
Month
Day
Year
Home Phone
Cel Phone
*
Work Phone
Email Address
Address
Street Address
City
Postal Code
Dental History
Former Dentist
How Long Have You Been a Patient There?
Date of Last Treatment ?
Date of Last Cleaning/Checkup?
Date of Last X-rays
Have you had any dental implants placed?
Yes
No
When did you have dental implants placed?
Do you wear any dental appliances
Check all that apply
Night Guard
Complete or Partial Denture
Orthodontic Appliance
Sleep Apnea Appliance
Oral Hygiene Habits
Do You Have Routine Cleanings?
Yes
No
How Often Do You Have Cleanings?
Every 3 Months
Every 4 Months
Every 6 Months
Every 12 Months
Do you use fluoridated toothpaste?
Yes
No
Number of Times You Brush
Per
(Day, Week, or Month)
Number of Times You Floss
Per
(Day, Week, or Month)
Do you experience any of the following?
Please check any that apply.
Bleeding/Sensitive Gums
Loose Teeth
Sensitivity to Hot or Cold
Popping or Clicking of the Jaw
Broken Teeth
Dry Mouth
Grinding or Clenching
Frequent Mouth Ulcers
History with Dental Specialists
Have you ever consulted any dental specialists? If yes, please list their name and year of treatment.
Endodontist (Root Canal Specialist)
Year Treated by Endodontist
Orthodontist (Braces/Invisiline)
Year Treated by Orthodontist
Periodontist (Gum Specialist)
Year Treated by Periodontist
Oral Surgeon
Year Treated by Oral Surgeon
Prosthodontist(Corwn and Bridge)
Year Treated by Prosthodontist
Is there any additional information about your dental history?
Describe
I certify that the above information is true and complete to the best of my knowledge.
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