Dentist Office

DENTAL HISTORY FORM

Dentist Office

Thank you and please call our office 215-560-8104 or email to info@academyhousedental.com if you have any questions.

Dental History

Why you are changing dentist? *
How long has it been since your last dental visit? *
Reason for the visit? *
Have you ever had a bad experience at the dentist?
Have you had any complications following dental treatment?
Have you experinced any bad reactions to dental anesthetic?
Does dental treatment make you nervous?
Are your teeth sensitive to cold, hot?
Do your gums bleed when you brush or floss?
Do you grind your teeth?
Are you aware of sores or irritated areas in the mouth?
Have you ever been treated for Periodontal Disease?
How often do you brush? *
How often do you floss? *
Do you like your smile?
If you could change your smile, what would you like to change?
I am interested in *

To ensure your visit is a great experience, please share any questions or concerns you would like us to know about.

Thanks for submitting!