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DENTAL HISTORY

Dental Information & History

You can easily fill out the form below, or if you prefer, download it as a document and complete it anytime.

Name:

Phone:

Email

Do your gums bleed when you brush or floss?

YES

NO

I DON'T KNOW

Do you have earaches or neck pains?

YES

NO

I DON'T KNOW

Are your teeth sensitive to cold, hot, sweets or pressure?

YES

NO

I DON'T KNOW

Do you have any clicking, popping or discomfort in the jaw?

YES

NO

I DON'T KNOW

Does food or floss catch between your teeth?

YES

NO

I DON'T KNOW

Do you brux or grind your teeth?

YES

NO

I DON'T KNOW

Do you have sores or ulcers in your mouth?

YES

NO

I DON'T KNOW

Have you had any periodontal (gum) treatments?

YES

NO

I DON'T KNOW

Do you wear dentures or partials?

YES

NO

I DON'T KNOW

Have you ever had orthodontic (braces) treatment?

YES

NO

I DON'T KNOW

Do you participate in active recreational activities?

YES

NO

I DON'T KNOW

Have you had any problems associated with previous dental treatment?

YES

NO

I DON'T KNOW

Have you ever had a serious injury to your head or mouth?

YES

NO

I DON'T KNOW

Is your home water supply fluoridated?

YES

NO

I DON'T KNOW

Do you drink bottled or filtered water?

YES

NO

I DON'T KNOW

If yes, how often? Circle one:

DAILY

WEEKLY

OCCASIONALLY

What was done at that time?

YES

NO

I DON'T KNOW

Are you currently experiencing dental pain or discomfort?

YES

NO

I DON'T KNOW

Date of last dental x-rays:

Date of your last dental exam:

What is the reason for your dental visit today?

How do you feel about your smile?

Thank you for contacting us.
We will get back to you as soon as possible.

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(954) 227-2718

contactus@innovationdentalfl.com

6180 West Sample Road, Coral Springs, FL 33067

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