DENTAL HISTORY

Name _______________________________ Date ________________________

Part 1. Dental Experiences and Symptoms

1. What is the main reason for your visit ? ( tujuan dari kedatangan)

2. When you look inside your mouth, do you know what to look for? (saat melihat
kedalam rongga mulut, apakah kamu tahu tahu apa yang harus diperiksa)

Yes No
Tooth Decay ( ) ( )
Oral Cancer ( ) ( )
Gum Disease ( ) ( )
Cold Sores ( ) ( )

3. Have you had dental x-rays in the past 2 years? (apakah pernah melakukan x-ray gigi
2 tahun belakangan ini)

( ) Yes Type ________ ( ) No

4. Have you had any complications or negative experiences associated with previous
dental treatment? (apakah pernah mengalami komplikasi/hal buruk saat melakukan
perawatan)

( ) Yes Explain ____________________

( ) No

5. Generally, how have you felt about your previous dental appointment? (apa yang
kamu rasakan pada perjanjian sebelumnya)

( ) Very anxious and afraid ( ) Dont care one way or the other
( ) Somewhat anxious and afraid ( ) Look forward to it

6. How much do you agree or disagree with this statement : oral health affects general
health (seberapa setujukah kamu akan kesehatan mulut memberi dampak pada kesehatan
tubuh)

( ) Strongly Agree ( ) Agree ( ) Disagree ( ) Strongly Disagree

7. Are you experiencing any the following symptoms?*please check all that apply
(apakah pernah merasakan gejala berikut)

( ) Sensitive Teeth ( ) Sore Jaw ( ) Toothache ( ) Bleeding Gums ( ) Difficult Chewing

( ) Filling fell out ( )Bad Breath ( ) Abscess ( ) Burning Sens. ( ) Tartar Buildup
( ) Yellowing Teeth ( ) Sinus Prob.( ) Difficult Swallowing ( ) Swelling Inside Mouth
 8. Do you clench or grind your teeth in the daytime or night?(apakah kamu
menggertakan gigimu sepanjang hari/malam hari)

( ) Yes ( ) No
If yes, do you wear a bite guard? _______ For how long? ________

9. In the past 2 years, have you been concerned about your breath or the appearance
of your teeth or face? (dalam 2 tahun ini apakah pernah khawatir akan bau mulut dan
penampilan gigi/wajah)

( ) Yellowing/Graying Teeth ( ) Spacing Between Teeth ( ) Bad Breath

( ) Stains ( ) Gums ( ) Crowded, Crooked Teeth
( ) Facial Profile

10. Have you experienced any injuries to your teeth, face and jaw? (apakah pernah
merasa sakit dibagian gigi,wajah atau rahang)

( ) Yes Explain __________________

( ) No

11. Have you experienced any of the following ? ( apakah pernah mengalami hal ini)
( ) Root Planning ( ) Gum Surgery ( ) Tooth Extractions ( ) Severe Pains of Face/Head
( ) Orthodontics ( ) Dental Implans ( ) Root Canals ( ) Bad React. to a local anestetic
( ) Jaw Surgery ( ) Head and Neck Radiation Therapy
( ) Prolonged Bleeding After Dental Treatment ( ) Other

Figure 3-1. Dental History form. (From Darby ML, Walsh MM : Dental Hygiene : theory and
practiced.3, Saunders,St.Louis,2010)