Do you Have or Have you ever Had? |
Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment :
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Please answer Yes or No to the following : |
PERSONAL HISTORY |
Are you fearful of dental treatment? |
Yes
No
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Have you had an unfavorable dental experience? |
Yes
No
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Have you ever had complications from past dental treatment? |
Yes
No
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Have you ever had trouble getting numb or reactions to local anesthetic? |
Yes
No
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Did you ever have braces, orthodontic treatment or had your bite adjusted? |
Yes
No
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Have you had any teeth removed |
Yes
No
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SMILE CHARACTERISTICS |
Is there anything about the appearance of your teeth that you would like to change ? |
Yes
No
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Have you ever whitened (bleached) your teeth ? |
Yes
No
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Are you self conscious about your teeth ? |
Yes
No
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Have you been disappointed with the appearance of previous dental work ? |
Yes
No
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BITE AND JAW JOINT |
Do you / would you have any problems chewing gum |
Yes
No
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Do you / would you have any problems chewing bagels or other hard foods |
Yes
No
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Have your teeth changed in the last 5 years, become shorter, thinner or worn |
Yes
No
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Are your teeth crowding or developing spaces |
Yes
No
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Do you have more than one bite or do you clench (squeeze) to make your teeth fit together |
Yes
No
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Do you have any problems with sleep or wake up with an awareness of your teeth? |
Yes
No
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Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) |
Yes
No
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Do you have tension headaches or sore teeth |
Yes
No
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Do you wear or have you ever worn a bite appliance |
Yes
No
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TOOTH STRUCTURE |
Have you had any cavities within the past 3 years |
Yes
No
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Do you have a dry mouth |
Yes
No
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Are any teeth sensitive to hot, cold, biting or sweets |
Yes
No
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Have you ever had a toothache, cracked filling, broken, chipped or cracked tooth |
Yes
No
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Do you avoid brushing any part of your mouth |
Yes
No
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Do you feel or notice any holes (i.e. pitting) in your teeth |
Yes
No
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GUM AND BONE |
Have you ever been diagnosed or treated for periodontal (gum) disease |
Yes
No
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Have you ever experienced gum recession |
Yes
No
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Is there anyone with a history of periodontal disease in your family |
Yes
No
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Do your gums bleed when brushing, flossing or eating |
Yes
No
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Are your teeth becoming loose |
Yes
No
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Have you ever noticed an unpleasant taste or odor in your mouth |
Yes
No
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Have you experienced a burning sensation in your mouth |
Yes
No
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