Dentistry on Danforth    Back to Forms

Dental History

249 Danforth Avenue, Toronto, ON, M4K 1N2      416-466-4422

Welcome to Dentistry on Danforth

In order to provide you with optimum dental care we require a thorough medical and dental history, which is unique to you. Be assured that all information is kept strictly confidential. Please take a moment to answer all questions on this questionnaire.

Personal Information

Patient's Name:
Patient's E-mail:
Patient's D.O.B.

Additional Information

Previous Dentist:
How long?
Last Dental Visit:
Last Dental X-Rays:
How often do you have your teeth cleaned?
Why did you leave your last dentist?
Immediate dental concern?
How often do you brush?
Do you use any devices other than a manual brush and floss?
If yes specify:
Please check YES or NO to each question. If unsure of a question, please consult with the dentist.
YesNo YesNo
unhappy with the appearance of your teeth? unfavourable dental experiences?
dental fears? problems with effectiveness or bad reactions to dental anaesthetic?
orthodontic treatment (braces)? periodontal (gum) treatment
bleeding, pain or swelling from gums? loose or shifted teeth?
food traps between teeth? growths or sore spots in your mouth?
teeth sensitive to heat, cold, sweets? teeth sensitive to pressure?
avoid brushing any part of your mouth? a burning sensation in your mouth?
difficulty swallowing? unpleasant taste or odour in your mouth?
dry mouth? jaw problems (temporomandibular joint)?
difficulty opening your mouth widely? stiff neck muscles?
awaken with an awareness of your teeth and jaws? tension headaches?
clench your teeth? grind your teeth?
jaw clicking or popping? do you wear a nightguard?
would you like your teeth to be whiter?
What do you like or dislike (or both) about your smile?
How nervous are you about dental treatment?

Supplemental Denture / Partial Denture History

(if you are wearing a partial or complete artificial denture please complete the following)

Has your present denture/partial been relined?
If yes, when?
Is your present denture/partial a problem?
If yes, describe
Satisfied with the appearance?
Satisfied with the comfort?
Satisfied with the chewing ability?
When did you receive your first partial or complete denture?
How long have you worn your present denture?

Release

I, the undersigned, certify that I have provided an accurate and complete personal dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my dental history. I understand that information provided from or to any other dental health care providers may be necessary, and I consent to the release of this information.

Patient/Parent/Guardian Signature: