Waukesha Family Dentistry - Dental History Form

Patient Name(*)

Please provide the patient or guardian's full name.

Date of Birth(*)

Please provide patient's date of birth.

Purpose of this initial visit?

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Are you aware of a problem?

YesNo Invalid Input

Previous Dentist's Name

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Previous Dentist's Address

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Previous Dentist's Phone Number

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What was done at that time?

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How long since your last dental visit?

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When was the last time your teeth were cleaned?

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General Dental History

Please choose the appropriate option for each question.

Please provide any additional information if asked - or write "don't know" in the line after the question.

Age

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Age

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Age

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Age

Invalid Input

Are you unhappy with your replacement?

YesNo Invalid Input

Why?

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Would you like to know about permanent replacements?

YesNo Invalid Input

History of Dental Conditions

Hygiene History

How and when do you brush your teeth?

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Do you use dental floss?

YesNo Invalid Input

How Often?

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Do you feel your breath is offensive at times?

YesNo Invalid Input

Other Dental History

Are any of your teeth loose, tipped, shifted, or chipped?

YesNo Invalid Input

Are you unhappy with the appearance of your teeth?

YesNo Invalid Input

Have you ever had gum treatment or surgery?

YesNo Invalid Input

Please describe the type of treatment, where, and when.

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Have you had any orthodontic work?

YesNo Invalid Input

Please describe

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Have you had any unpleasant dental experiences or is there anything about dentistry that you strongly dislike?

YesNo Invalid Input

Please explain

Invalid Input

Do you have any questions or concerns?

YesNo Invalid Input

I certify that the above information is complete and accurate. Please check the box confirming the validity of these statements.

Electronic Signature(*)

Sign Above

Please provide an electronic signauture

Dental History

General Dental History

Please choose the appropriate option for each question.

Tooth Loss & Replacement History

History of Dental Conditions

Hygiene History

Other Dental History