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    • Dr. Paresh Shah
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(204) 837-4517

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Call Today: (204) 837-4517
Book Appointment
  • Services
    • Digital Dentistry
    • Dental Implants
    • Aesthetics
    • Comprehensive Care
  • LECTURES & WORKSHOPS
  • Digital Smile Design
  • Smile Consult
  • Meet Our Doctors
    • Dr. Paresh Shah
    • Dr. Neil Wilson
  • Meet Our Team
  • Contact
  • Dental History Form

    If you have any questions, please call our office at 204-837-4517.

    DENTAL HISTORY
     
    First Name Last Name
    Reffered by How would you rate the condition of your mouth?
    Excellent
    Good
    Fair
    Poor
    Previous Dentist How long have you been a patient? Month/Years
    Date of most recent dental exam Date of most recent x-rays
    Date of most recent treatment (other than a cleaning)
    I routinely see my dentist every:
    3 mo.
    4 mo.
    6 mo.
    12 mo.
    Not routinely
    WHAT IS YOUR IMMEDIATE CONCERN?
     
    PLEASE ANSWER YES OR NO TO THE FOLLOWING:
     
     
    PERSONAL HISTORY
     
    1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) []
    Yes
    No
     
    2. Have you had an unfavorable dental experience?
    Yes
    No
     
    3. Have you ever had complications from past dental treatment?
    Yes
    No
     
    4. Have you ever had trouble getting numb or had any reactions to local anesthetic?
    Yes
    No
     
    5. Did you ever have braces, orthodontic treatment or had your bite adjusted?
    Yes
    No
     
    6. Have you had any teeth removed?
    Yes
    No
     
     
     
    SMILE CHARACTERISTICS
     
    7. Is there anything about the appearance of your teeth that you would like to change?
    Yes
    No
     
    8. Have you ever whitened (bleached) your teeth?
    Yes
    No
     
    9. Have you felt uncomfortable or self conscious about the appearance of your teeth?
    Yes
    No
     
    10. Have you been disappointed with the appearance of previous dental work?
    Yes
    No
     
     
     
    BITE AND JAW JOINT
     
    11. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
    Yes
    No
     
    12. Do you / would you have any problems chewing gum?
    Yes
    No
     
    13. Do you / would you have any problems chewing bagels, baguettes , protein bars, or other hard foods?
    Yes
    No
     
    14. Have your teeth changed in the last 5 years, become shorter, thinner or worn?
    Yes
    No
     
    15. Are your teeth crowding or developing spaces?
    Yes
    No
     
    16. Do you have more than one bite and squeeze to make your teeth fit together?
    Yes
    No
     
    17. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
    Yes
    No
     
    18. Do you clench your teeth in the daytime or make them sore?
    Yes
    No
     
    19. Do you have any problems with sleep or wake up with an awareness of your teeth?
    Yes
    No
     
    20. Do you wear or have you ever worn a bite appliance?
    Yes
    No
     
     
     
    TOOTH STRUCTURE
     
    21. Have you had any cavities within the past 3 years?
    Yes
    No
     
    22. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?
    Yes
    No
     
    23. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
    Yes
    No
     
    24. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth?
    Yes
    No
     
    25. Do you have grooves or notches on your teeth near the gum line?
    Yes
    No
     
    26. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling?
    Yes
    No
     
    27. Do you get food caught between any teeth?
    Yes
    No
     
     
     
    GUM AND BONE
     
    28. Do your gums bleed when brushing or flossing?
    Yes
    No
     
    29. Have you ever been treated for gum disease or been told you have lost bone around your teeth?
    Yes
    No
     
    30. Have you ever noticed an unpleasant taste or odor in your mouth?
    Yes
    No
     
    31. Is there anyone with a history of periodontal disease in your family?
    Yes
    No
     
    32. Have you ever experienced gum recession?
    Yes
    No
     
    33. Have you ever had any teeth become loose on their own (without an injury),
    or do you have difficulty eating an apple?
    Yes
    No
     
    34. Have you experienced a burning sensation in your mouth?
    Yes
    No
     
     
    Patient’s Signature
    Clear
    OK
    Date
     
    Doctor’s Signature
    Clear
    OK
    Date
     
     
     

    6-3421 Portage Ave.
    Winnipeg, MB R3K2C9

    204-837-4517

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