Comprehensive Dental History | Luxury Tooth Booth Inc.

1. Patient and Form Information

Patient Full Legal Name *

Date of Birth *

Today's Date *

Person Completing This Form *

Name and relationship of person completing form, if not the patient

2. Current Dental Provider

Primary Dentist Name

Dental Office / Practice Name

Dental Office Phone Number

Dental Office Email, if known

Date of Last Dental Exam, if known

Date of Last Dental Cleaning, if known

Is the patient currently under the care of a dentist or dental specialist? Please list provider and reason, if applicable.

3. Current Dental Concerns or Alerts

If the patient currently has facial swelling, fever, drainage, uncontrolled bleeding, severe dental pain, or difficulty swallowing or breathing, contact an appropriate dentist, physician, urgent-care service, or emergency service. Luxury Tooth Booth Inc. may recommend referral before routine dental hygiene services.

Is the patient currently experiencing an urgent oral-health concern?

Primary concern, if applicable

Please describe any current dental concerns, changes, discomfort, or alerts.

4. Gum and Periodontal Health

Select any items the patient currently experiences or has previously been told about.

Bleeding gums when brushing, flossing, or eating

Red, tender, swollen, or inflamed gums

Gum recession or teeth appearing longer

Deep gum pockets or history of periodontal/gum disease

Bone loss around teeth, if known

Loose, shifting, or separating teeth

Changes in bite or in denture/partial-denture fit

None known

Not sure

Please share any known gum-disease history, deep cleanings, periodontal treatment, or concerns.

5. Tooth and Structural Health

Sensitivity to hot, cold, sweet, acidic, or salty foods/drinks

Frequent cavities or concern about recurring decay

Cracked, chipped, broken, or worn teeth

Food trapping between teeth

Difficulty chewing or pain when biting

Broken, missing, or loose filling, crown, bridge, or other restoration

Dark area, discoloration, or tooth change of concern

None known

Not sure

Please describe tooth-specific concerns and the location in the mouth, if known.

6. Oral Environment and Comfort

Please provide details about oral comfort, saliva, taste, tissue, swallowing, or appliance concerns.

7. Previous Dental Treatment and Trauma

History of dental, jaw, head, face, or neck trauma?

Approximate trauma date, if known

Please provide important treatment history, trauma details, complications, or preferences.

8. Jaw, TMJ, and Muscle Function

Jaw pain, soreness, fatigue, or stiffness

Clicking, popping, or grinding sounds in the jaw joints

Limited mouth opening or jaw locking

Head, face, neck, shoulder, or temple tension

Clenching or grinding teeth during the day or night

Jaw trauma or injury

Frequent headaches or migraines

None known

Not sure

Please describe jaw, muscle, headache, or facial-tension concerns.

9. Airway and Sleep Screening

Screening only: These questions are intended to identify concerns that may warrant education or referral. They do not diagnose sleep apnea or another sleep disorder.

Has the patient been diagnosed with sleep apnea?

Has the patient had a sleep study?

Current sleep treatment, if applicable

CPAP/BiPAP use or tolerance, if applicable

Please provide any sleep-study, CPAP/BiPAP, oral-appliance, snoring, or airway-health notes.

For Pediatric Patients Only

10. Oral Hygiene Routine and Product Preferences

How often does the patient brush?

How often does the patient clean between teeth?

Tools currently used

Does the patient have holistic, biological, ingredient-conscious, low-toxicity, fragrance-free, or fluoride-free oral-care preferences?

Does the patient use mouth rinse?

Please list current oral-care products, including toothpaste, rinse, floss/interdental cleaners, denture products, oral-appliance cleaner, and product preferences or sensitivities.

11. Dental Materials and Individual Considerations

Silver-colored amalgam fillings, current or previous

Previous removal or replacement of amalgam fillings

Known or suspected sensitivity to dental materials or metals

History of frequent or extensive dental treatment

Questions or concerns about dental materials

None known

Not sure

Please describe material history, sensitivities, concerns, or preferences.

12. Whole-Person Symptoms and Patient Goals

These questions support comfort, prevention, education, and care coordination. They do not diagnose medical conditions.

Current symptoms or concerns

Patient goals

Prevent cavities and protect natural teeth

Improve gum health and periodontal stability

Maintain natural teeth long-term

Explore conservative and minimally invasive options when clinically appropriate

Improve smile appearance or learn about whitening options

Learn how oral health may relate to overall health and wellness

Learn more about airway, snoring, mouth breathing, or sleep-health considerations

Other goal

Please share additional symptoms, priorities, comfort needs, questions, or goals.

13. Attestation and Electronic Signature

I confirm that the information provided in this questionnaire is accurate and complete to the best of my knowledge. I understand that I should notify Luxury Tooth Booth Inc. of changes in oral health, medications, allergies, dental providers, medical history, or care needs.

Name of Person Signing *

Relationship or Role *

Date Signed *

Electronic Signature *

By typing your full legal name, you intend to sign this form electronically.