Medical Dental Building     509 Olive Way, Suite 1414     Seattle, WA 98101     (206) 623-3122
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Roger J. Harper D.D.S, M.S.D, PS,  Restorative Dentistry

DENTAL HISTORY FORM

 

Your Name           Email Address  

Please indicate any of the following conditions which apply to your health status:

Early tooth decay Periodontal disease (pyorrhea)
Orthodontic treatment TMJ, TMD, Jaw joint problem
Crowns and/or bridges Removable partial denture
Loose teeth Sensitive teeth
Swellings on gum Difficulty opening widely
Pain in jaw joint Ear problems or ringing
Nightguard, retainer Clenching, grinding of teeth
Sore teeth Periodontal surgery
"Novocaine" reaction Premedication required (by Dr.)
Root canals Bleeding gums

Previous Dentist      City         Last Visit        

Please request a release of your former dental records.

Last dental x-rays  
Last dental cleaning  
Cleanings per year  
Frequency of brushing (per day)
Frequency of flossing (per day)
Other hygiene aids

 If you are dissatisfied with the appearance of your teeth, please explain:

Current problem, or reason for today's visit:

Whom may we thank for referring you to our office?   

Is there any condition or problem not previously listed that you feel we should know about?

 

  

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