Patient Form Pg3


When was your last dental visit?
Your last dental cleaning?
Do any of the following cause you discomfort?
Do you have any difficulty chewing food on either side of your mouth?
Do you have any digestive problems?
Do you have any missing teeth?
Have your missing teeth ever been replaced?
If so, how?
Do you have any loose teeth?
Do you have any cracked or broken teeth?
Do you do any of these more than once per day?
Drink soda drinks
Use breath mints
Chew gum
Have you ever had a grinding appliance, guard, or any other treatment for your bite?
Do you ever clench of grit your teeth?
Do you ever have/or ever had any headaches?
Do you ever have/ or ever had ear pain?
Do you ever have/or ever had tension, aching, or a tired feeling in you jaws?
Do you ever have/or have you ever had clicking or popping in your jaws or ears?
Have you ever had any gum problems?
If yes, was it treated
Do/did your parents have dentures or gum disease?
Do your gums bleed while brushing or flossing?
Do you floss your teeth more than 3 times per week? (Be honest – most don’t floss!)
Are you a smoker?
Have you ever had orthodontic treatment?
Have you ever whitened (bleached) your teeth?
Have you ever considered tooth whitening?
Are you unhappy with your smile?
If yes, what would you change
Straighten/get rid of spaces
Make teeth Larger
Make teeth Smaller
Does dental treatment cause anxiety for you?
Have you ever had an unpleasant experience at the dentist?
Would you ever consider being sedated for dental treatment?
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