Dental History - Perk Dental

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HOME
ABOUT US
SERVICES
NEW PATIENTS
BLOG
CONTACT US

Book Appointment

832-930-7843

Dental History

Dental History

Dental History

Name*

First Name

Last Name

Email Address *

Phone Number *

How do you feel about dental treatment?

Relaxed

A little uneasy

Tense

Anxious

Very Anxious

Have you seen a dentist before?

Yes

No

If so, when was your last dental visit?

How would you rate your previous dental experience?

What are your dental concerns?

Have you avoided regular dental care?

Yes

No

If so, why have you avoided regular dental care?

Are you happy with the appearance of your teeth?

Yes

No

If not, why are you unhappy with the appearance of your teeth?

How often do you brush?

How often do you floss?

How often do you use other aids?

New Field:

Would you like your teeth to be whiter?

Yes

No

Would you like your teeth to be straighter?

Yes

No

Do you have, or have you ever had any of the following dental conditions? Please check all that apply. *

Aching or sensitive teeth

Areas of food traps

Broken filling

Cavities

Cold sores

Dry mouth

Facial surgery

Growths or lesions in your mouth

Gum treatments

Jaw clenching

Night guard

Orthodontic treatment

Swelling or lumps in mouth

Teeth grinding

Active decay of teeth or gums

Bad breath

Broken or missing teeth

Clicking or popping jaw

Difficulty opening wide

Aesthetic concerns with teeth

Gag easily

Gum infection / disease

Jaw pain or tiredness

Loose teeth

Oral surgery

Sensitive or bleeding gums

Swollen glands

Unfavorable dental experience

None of the above

Previous dentist or dental office

New Field:

City

State / Province***

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in status.

Thank you for contacting us.
We will get back to you as soon as possible.

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Contact Information

Phone: 832-930-7843

Fax : 281-692-2254

info@perkdental.com

10237 Bailey Road Suite 107, Manvel, Texas 77578

perk up your smile

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How did you hear about us:

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Perk Dental.

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