Dental History Questionnaire

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519-822-3888

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info@guelphdentalcare.ca

5 Woodlawn Rd West, Suite 104 Guelph, Ontario N1H 1G8

Office Hours:

Mon - Fri: 10-7 | Sat: 9-5 | Sun: Closed

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The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. The dentist will review the questions and explain any that you do not understand. Please fill in the entire form.

1 What is the reason for your visit today? Are you currently experiencing any dental problems?

2) Have you been seeing a dentist regularly? If not, why not?

Yes

OtherOther

3) Are you nervous during dental visits?

Yes

Not Sure/Maybe

4) Have you had a bad experience or complications during dental treatment?

Yes

Not Sure/Maybe

5) When was your last dental visit? What was done at that appointment?

6) When did you last have dental x-rays?

7) Have you ever seen a dental specialist?

Yes

Not Sure/Maybe

8) How often do you brush your teeth? How often do you floss? Do your gums bleed when you brush or floss?

9) Have you been told to take antibiotics before a dental appointment?

Yes

Not Sure/Maybe

10) Do you feel that you have bad breath?

Yes

Not Sure/Maybe

11) Are you happy with the appearance of your teeth?

Yes

Not Sure/Maybe

12) Do you have any problems with your jaw (clicking, limited movement, pain)?

Yes

Not Sure/Maybe

13) Have you ever had an injury to the teeth or jaws or been involved in a motor vehicle accident?

Yes

Not Sure/Maybe

To the best of my knowledge, the above information is correct:

Patient/Parent/Guardian Signature:

Date

Dentist Signature:

Date

DENTIST’S NOTES:

If you are human, leave this field blank.

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Dental History Questionnaire

To the best of my knowledge, the above information is correct:

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