Dental History

Dental History

All fields marked with * are required.
*Date of Birth
*What is the reason for your visit today?
Date of Last Dental Visit
Last Dental Cleaning
Last Full Mouth X-Rays
What was done at your last dental visit?
*Do you have a previous dentist?
*How often do you see the dentist?
*How often do you brush your teeth?
*How often do you floss?
*What type of toothbrush do you use?
*Do you use mouthwash?
*Do you use any other dental home care products?
*Do you have any dental problems now?
Are any of your teeth sensitive to:
*Biting or Chewing
*Do you have dry mouth?
*Have you noticed any mouth odors or bad tastes?
*Do you frequently get cold sores, blisters or any other oral lesions?
*Do your gums bleed or hurt when brushing?
*Have you noticed any loose teeth?
*Have you noticed any change in your bite?
*Does food tend to become caught between your teeth?
Do you:
*Clench or grind your teeth while awake or asleep?
*Bite your lips or cheeks regularly?
*Hold foreign objects with your teeth? (Pencils, pipe, pens)
*Mouth breathe while awake or asleep?
*Snore or have been told that you snore?
Have you ever had:
*Orthodontic treatment?
*Oral surgery?
*Periodontal treatment?
*A night guard or mouth guard?
*A serious injury to the mouth or head?
Have you experienced:
*Clicking or popping of the jaw?
*Pain? (joint, ear, side of face)
*Difficulty in opening or closing the mouth?
*Headaches, neck aches, or shoulder aches?
*Tired jaws, especially in the morning?
*Would you like to keep all of your teeth all of your life?
*Do you feel nervous about having dental treatment?
*Have you ever had an upsetting dental experience?
*Is there anything you would change about your smile?
What is important to you in a dentist or dental practice?
So we can care for you in the best possible way, what else would you like us to know?


36 N. San Mateo Drive, Suite B, San Mateo, CA 94401

Office Hours

MON - WED 8:00 am - 5:00 pm

THU - FRI 7:00 am - 3:30 pm

SAT - SUN Closed

Get in Touch


Phone: (650) 342-0474