Your SW Calgary Family & General Dentist

Email:info@ultimadentalwellness.ca

Phone:(403) 259-3401

Book Now

Dental history

DENTAL HISTORY

Patient Name

Preffered

Age

How would you rate the condition of your mouth?GoodFairPoor

Previous Dentist

Date of most recent dental exam

Date of most recent x-rays Months/Years

WHAT IS YOUR IMMEDIATE CONCERN?

PLEASE CHECK TO ANSWER YES TO ANY OF THE FOLLOWING QUESTIONS:

PERSONAL HISTORY

CHECK IF YES

1. Are you fearful of dental treatment?

2. Have you had an unfavorable dental experience?

3. Have you ever had trouble getting numb or had any reactions to local anesthetic?

4. Did you ever have braces, orthodontic treatment or had your bite adjusted?

GUM AND BONE

CHECK IF YES

5. Do your gums bleed sometimes or are they ever painful when brushing or flossing?

6. Have you ever noticed an unpleasant taste or odor in your mouth?

7. Is there anyone with a history of periodontal disease in your family?

8. Have you ever experienced gum recession?

TOOTH STRUCTURE

CHECK IF YES

9. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food?

10. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your
teeth?

11. Do you have grooves or notches on your teeth near the gum line?

12. Have you ever broken teeth, chipped teeth, or had a toothache or cracked
filling?

13. Do you frequently get food caught between any teeth?

BITE AND JAW JOINT

CHECK IF YES

13. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

14. Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?

15. Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?

16. In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?

17. Are your teeth developing spaces or becoming more loose?

18. Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?

19. Do you place your tongue between your teeth or close your teeth against your tongue?

20. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?

21. Do you clench or grind your teeth together in the daytime or make them sore?

22. Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?

23. Do you wear or have you ever worn a bite appliance?

SMILE CHARACTERISTICS

CHECK IF YES

24. Is there anything about the appearance of your mouth (smile, lips, teeth, gums) that you would like to change(shape, color, size, display)?

25. Have you ever whitened (bleached) your teeth?

26. Have you felt uncomfortable or self-conscious about the appearance of your teeth?

27. Have you been disappointed with the appearance of previous dental work?

Patient’s Signature

Date Signed

81539

The Ultima Dental Wellness team is committed to working together to ensure that every patient who visits us has an experience that exceeds their expectations, each and every time!

Quick Links

Practice Hours

Our
Practice Hours

Monday: 8:00 am to 3:00 pm

Tuesday: 9:00 am to 6:00 pm

Wednesday: 9:30 am to 6:00 pm

Thursday: 7:00 am to 4:00 pm

Friday: 8:00 am to 4:00 pm

Saturday: By Appointment Only

Sundays: Closed

Statutory Holidays: Closed

Contact Us

#202, 506 – 71 Avenue SW
Calgary, Alberta
T2V 4V4

(403) 259-3401 info@ultimadentalwellness.ca

Disclaimer

The dentists at Ultima Dental Wellness are all General Dentists. As general dentists, they provide cosmetic dental procedures such as porcelain veneers, dental crowns, dental braces, and teeth whitening as part of their General Dentistry license. Cosmetic Dentistry & Family Dentistry are not recognized dental specialties by the Alberta Dental Association & College of Dental Surgeons of Alberta (CDSA). As SW Calgary Dentists, they provide General Dental procedures for all ages within the family.

Creative with by Creative Pixel Media

Dental history

DENTAL HISTORY

PLEASE CHECK TO ANSWER YES TO ANY OF THE FOLLOWING QUESTIONS:

PERSONAL HISTORY

GUM AND BONE

TOOTH STRUCTURE

BITE AND JAW JOINT

SMILE CHARACTERISTICS

Quick Links

Practice Hours

Our Practice Hours

Contact Us

Disclaimer

Our
Practice Hours