Patient Dental History

Southfield Dentist

Patient Name

Your Email (required)

What dental care would you like us to provide today?

When was your last dental visit?

YesNo - Are you having PAIN, SWELLING, or SORE SPOTS at this time?
YesNo - Do your GUMS BLEED?
YesNo - Have you had GUM TREATMENTS?
YesNo - If you SNORE, would you like an oral device to help you?
YesNo - Do you have BAD BREATH?
YesNo - Is this your FIRST VISIT to any dentist?
YesNo - Have you had any complications with dental treatment?
YesNo - Have you been treated for TMJ (Temporomandibular joint) problems?
YesNo - Do you have REMOVABLE UPPER dentures or partials?
YesNo - Do you have REMOVABLE LOWER dentures or partials?
YesNo - Do you have a FEAR of dentistry?
YesNo - Do you like your SMILE?
YesNo - Have you had a complete set of X-RAYS taken in the past 3 years?
YesNo - Have you visited our website at

In order for us to provide you with the best quality of care, we like to get to know you better. As a provider, all of the following are important to us, however, we would like to know which is most important to you.

When considering having treatment done, which of the following would be a concern for you?

What would you say would be the most important quality for you in a relationship with your dentist?