Dental History

Dental History

All fields marked with * are required.
*Name
*Date of Birth
*What is the reason for your visit today?
Date of Last Dental Visit
Last Dental Cleaning
Last Full Mouth X-Rays
What was done at your last dental visit?
*Do you have a previous dentist?
*How often do you see the dentist?
*How often do you brush your teeth?
*How often do you floss?
*What type of toothbrush do you use?
*Do you use mouthwash?
*Do you use any other dental home care products?
*Do you have any dental problems now?
Are any of your teeth sensitive to:
*Hot
*Cold
*Sweets
*Biting or Chewing
*Do you have dry mouth?
*Have you noticed any mouth odors or bad tastes?
*Do you frequently get cold sores, blisters or any other oral lesions?
*Do your gums bleed or hurt when brushing?
*Have you noticed any loose teeth?
*Have you noticed any change in your bite?
*Does food tend to become caught between your teeth?
Do you:
*Clench or grind your teeth while awake or asleep?
*Bite your lips or cheeks regularly?
*Hold foreign objects with your teeth? (Pencils, pipe, pens)
*Mouth breathe while awake or asleep?
*Snore or have been told that you snore?
Have you ever had:
*Orthodontic treatment?
*Oral surgery?
*Periodontal treatment?
*A night guard or mouth guard?
*A serious injury to the mouth or head?
Have you experienced:
*Clicking or popping of the jaw?
*Pain? (joint, ear, side of face)
*Difficulty in opening or closing the mouth?
*Headaches, neck aches, or shoulder aches?
*Tired jaws, especially in the morning?
*Would you like to keep all of your teeth all of your life?
*Do you feel nervous about having dental treatment?
*Have you ever had an upsetting dental experience?
*Is there anything you would change about your smile?
What is important to you in a dentist or dental practice?
So we can care for you in the best possible way, what else would you like us to know?



36 N. San Mateo Drive, Suite B
San Mateo, 94401

Olson Dental

36 N. San Mateo Drive, Suite B

Mob: (650) 342-0474

MON - WED : 8:00 am - 5:00 pm

THU - FRI : 7:00 am - 3:30 pm

SAT - SUN : Closed