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Menu
Home
Office Info
About Us
Office Policies & Mission
Map & Directions
Financial & Insurance
Contact Us
Patient Info
First Dentist Appointment
Patient Forms
Dental Health
Brushing & Flossing
Common Dental Problems
Emergency Care
Treatments
Preventive Dentistry
General Treatment
Benefits
Am I a Good Candidate?
FAQs
TMJ / TMD
Dental Crowns
Dentures
Benefits
Am I a Candidate?
Aftercare
Facts
Misconceptions
Dental Implants
Benefits
Am I a Candidate?
FAQs
Aftercare
Facts
Misconceptions
Cosmetic Dentistry
Cosmetic Dentist
Benefits
FAQs
Aftercare
Facts
Misconceptions
Teeth Whitening
Benefits
Am I a Candidate?
FAQs
Porcelain Veneers
Benefits
Who Is a Candidate?
Aftercare
FAQs
Invisalign
Benefits
Am I a Candidate?
FAQs
Aftercare
Traditional Braces
Benefits
FAQs
Sedation Dentistry
Children’s Dentistry
Benefits
FAQs
Endodontics
Benefits
Am I a Candidate?
FAQs
Periodontics
Technology
Smile Gallery
Testimonials
Contact Us
Map & Directions
Patient Satisfaction & Feedback
Blog
Dental History Form
Patient Dental History
Reason for today's visit
*
Date last seen by a dentist
Date of last x-ray
*
Date of last cleaning
*
Have you ever been treated for periodontal disease?
*
If so, when?
*
How often do you brush your teeth?
*
How often do you floss?
Do you have any of the following?
Mouth odor or bad taste:
Yes
No
Bleeding Gums:
Yes
No
Loose teeth:
Yes
No
Broken teeth or broken fillings:
Yes
No
Does food collect between your teeth:
Yes
No
Chew on one side of your mouth:
Yes
No
Are your teeth sensitive:
Yes
No
If you do have sensitivity, what triggers it?
(Biting, chewing, sweets or other)
Clicking or popping in jaws:
Yes
No
Grinding teeth:
Yes
No
Jaw pain or tiredness:
Yes
No
Difficulty opening or closing:
Yes
No
Headaches neck aches or shoulder aches:
Yes
No
Sore muscles:
Yes
No
Do you currently or have you ever wore a night guard?
Yes
No
Orthodontic retainer?
Yes
No
Have you ever had orthodontic treatment?
*
Yes
No
Treating Doctor:
Have you ever had oral surgery?
*
Yes
No
Treating Doctor:
Are you satisfied with your teeth’s appearance?
Yes
No
If not, explain why:
Are you nervous about dental treatment?
Yes
No
If so, what is your biggest concern?
Any other information you would like Dr. Buzbee to know?
Name
*
First
Last
Signature
*
Date
*
Month
Day
Year