Dental History Form - Dr. David A. Knopf

General Information

Name *

First

Last

Date of Birth *

Dental Health History

Are you apprehensive about dental treatment *

Yes
No

Have you had problems with previous dental treatment? *

Yes
No

Do you gag easily? *

Yes
No

Do you wear dentures? *

Yes
No

Does food catch between your teeth? *

Yes
No

Do you have difficulty chewing your food? *

Yes
No

Do you chew on only one side of your mouth? *

Yes
No

Do you chew on only one side of your mouth because of pain? *

Yes
No

Do your gums bleed easily? *

Yes
No

Do your gums feel swollen or tender? *

Yes
No

Have you ever noticed slow-healing sores in or about your mouth? *

Yes
No

Are your teeth sensitive? *

Yes
No

Do you feel twinges of pain when your teeth come in contact with hot foods or liquids? *

Yes
No

Cold foods or liquids? *

Yes
No

Sours? *

Yes
No

Sweets? *

Yes
No

Do you take fluoride supplements? *

Yes
No

Are you dissatisfied with the appearance of your teeth? *

Yes
No

Do you prefer to save your teeth? *

Yes
No

Do you want complete dental care? *

Yes
No

How often do you brush? *

How often do you floss? *

Does your jaw make noise so that it bothers you or others? *

Yes
No

Do you clench or grind your jaws frequently? *

Yes
No

Do your jaws ever feel tired? *

Yes
No

Does your jaw get stuck so that you can't open or close freely? *

Yes
No

Does it hurt when you chew or open wide to take a bite? *

Yes
No

Do you have earaches or pain in front of the ears? *

Yes
No

Do you have any jaw symptoms or headaches upon awaking in the morning? *

Yes
No

Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities? *

Yes
No

Do you find jaw pain or discomfort extremely frustrating or depressing? *

Yes
No

Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)? *

Yes
No

Do you have a temporomandibular (jaw) disorder (TMD)? *

Yes
No

Do you have pain in the face, cheeks, jaws, joints, throat, or temples? *

Yes
No

Are you unable to open your mouth as far as you want? *

Yes
No

Are you aware of an uncomfortable bite? *

Yes
No

Have you had a blow to the jaw (trauma)? *

Yes
No

Are you a habitual gum chewer or pipe smoker? *

Yes
No

Do you snore? *

Yes
No

Are you excessively tired during the day? *

Yes
No

Have you been told you stop breathing during sleep? *

Yes
No

Is your neck size greater than 17 inches (male) or 16 inches (female)? *

Yes
No

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