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Merrimack Valley Dental Care
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Dental History
Name
Phone
Email
How do you feel about dental treatment?
Relaxed
A little uneasy
Tense
Anxious
Very Anxious
Have you seen a dentist before?
Yes
No
If so, when was your last dental visit?
Within the last 3 months
Within the last 3-6 months
Within the last 6-9 months
Within the last 9-12 months
More than 1 year
More than 2 years
More than 5 years
Never
How would you rate your previous dental experience?
Excellent
Good
Average
Poor
What are your dental concerns?
Have you avoided regular dental care?
Yes
No
If so, why have you avoided regular dental care?
Are you happy with the appearance of your teeth?
Yes
No
If not, why are you unhappy with the appearance of your teeth?
How often do you brush?
Less than once per week
Once per week
Several times per week
Once per day
Twice per day
Three times per day
How often do you floss?
Less than once per week
Once per week
Several times per week
Once per day
Twice per day
Three times per day
How often do you use other aids?
Less than once per week
Once per week
Several times per week
Once per day
Twice per day
Three times per day
Would you like your teeth to be whiter?
Yes
No
Would you like your teeth to be straighter?
Yes
No
Do you have, or have you ever had any of the following dental conditions? Please check all that apply.
Aching or sensitive teeth
Active decay of teeth or gums
Areas of food traps
Bad breath
Broken filling
Broken or missing teeth
Cavities
Clicking or popping jaw
Cold sores
Difficulty opening wide
Dry mouth
Aesthetic concerns with teeth
Facial surgery
Gag easily
Growths or lesions in your mouth
Gum infection / disease
Gum treatments
Jaw pain or tiredness
Jaw clenching
Loose teeth
Night guard
Oral surgery
Orthodontic treatment
Sensitive or bleeding gums
Swelling or lumps in mouth
Swollen glands
Teeth grinding
Unfavorable dental experience
None of the above
Previous dentist or dental office
Name of previous dentist or dental office
City
State / Province
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in status.
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