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Dental Health History Template
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We're committed to providing you with the best possible care. By understanding your dental history, we can tailor our treatments to meet your unique needs. Thank you for sharing your insights with us!
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1.
What is your full name?
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2.
What is your age group?
18-24
25-34
35-44
45-54
55-64
65
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3.
What is your gender?
Male
Female
Prefer not to say
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4.
How often do you brush your teeth?
Once a day
Twice a day
Three times a day
More than three times a day
Rarely
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5.
How often do you floss your teeth?
Once a day
Twice a day
Three times a day
More than three times a day
Rarely
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6.
Have you ever had the following situations?
[Checkboxes]
Cavity
Root canal
Braces
Tooth extracted
Dental implants
Gum disease
Wisdom teeth removed
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7.
Do you experience any pain or discomfort in your teeth or gums?
Yes
No
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8.
Have you ever had a teeth whitening treatment?
Yes
No
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9.
How often do you visit the dentist for a checkup?
Every 6 months
Once a year
Less than once a year
Only when I have a problem
10.
Is there anything else you would like to share about your dental health history?
10
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