Dental History
What are your primary dental concerns?
Are you having any discomfort at this time? If so, in what area?
Are yo nervous about having dental treatment?
How do you feel about the color and general appearance of your teeth?
How often to you floss?
How often do you brush?
Have you ever had periodontal (gum) surgery or treatment?
If so, how long ago?
Have you ever had orthodontic (braces) treatment?
If so, how long ago?
Have you ever had or have TMJ (Jaw clicking or popping, frequent headaches) disorder?
Have you ever had or have you ever worn a bite appliance (nightguard)?
Are your teeth sensitive to?
Problems of the jaw?
When was your last dental appointment?
Phone Number
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Date
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Month
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Day
Year
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