San Jose :
+1 (408) 943 9443
sanjose@smiles-r-us.com
Home
About Us
Services
For Patients
Gallery
Blog
Contact Us
Toggle navigation
Home
About Us
Services
For Patients
Gallery
Blog
Contact Us
Home
- For Patients
For Patients
Patient Resources
Patients Forms
Dental Material Factsheet
Financial Policy
Acknowledgement of privacy and facts
Notice of privacy
Cancelation Policy
New Patient Forms
Patient Forms
Insurance
Office Ammenities
What To Expect On Your 1st Visit
Reviews
Blog
New Patient Forms
Step 04: Dental History
Reason for today’s visit
Former Dentist
City / State
Date of last dental visit :
Date of last dental x-rays
Place a mark on "yes" or "no" to indicate if you have had any have had any of the following:
Bad breath
Yes
No
Bleeding Gums
Yes
No
Blisters on lip or mouth
Yes
No
Burning Sensation on toungue
Yes
No
Chew on one side of mouth
Yes
No
Cigarete, pipe or cigar smoking
Yes
No
Clicking or poping jaw
Yes
No
Dry Mouth
Yes
No
Fingernail biting
Yes
No
Food collection between the teeth
Yes
No
Foreign objects
Yes
No
Grinding teeth
Yes
No
Gums swollen or tender
Yes
No
Jawpain or tiredness
Yes
No
Lip or cheek biting
Yes
No
Loose teeth or broken fillings
Yes
No
Mouth breathing
Yes
No
Mouth pain, brushing
Yes
No
Orthodontic treatment
Yes
No
Pain around ear
Yes
No
Periodontal treatment
Yes
No
Sensitivity to cold
Yes
No
Sensitivity to head
Yes
No
Sensitivityy to sweets
Yes
No
Sensitivity when biting
Yes
No
Sores or growths in your mouth
Yes
No
How often do you floss?
How often do you brush?
Reset
Save & Next
Book an Appoinment