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Crowns, Bridges, Dentures, Veneers, Cosmetic Dentistry, Preventive Dentistry

Dental History

DENTAL HISTORY


Please let us know the Patient's name.
Please indicate the Patient's Email Address
Please provide the Patient's Birthday.

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Please let us know what the Purpose of your call is.
Please let us know the previous Dentist street address.
Please let us know the Previous Dentist street address 2 (suite number)
Please indicate the Previous Dentist City
Please select a Previous Dentist State
Please indicate the Previous Dentist Zip Code

QUESTIONNAIRE


Please Choose whether you are aware of a problem
Please let us know how long since your last dental visit?
Please let us know what was done at your last dentist visit?
Please let us know when your last teeth cleaning was?
Please tells us how often you visited the Dentist
Please Choose whether you regular visits to your Dentist
Please Choose if Xrays were taken at your last Dental visit.
Please Choose if you lost any teeth or have any teeth been removed?
Please let us know why you lost teeth.
Please Choose if your teeth been replaced.
Please tells us how often you visited the Dentist
Please Choose if your teeth been replaced.
If you said "YES", that you were happy with the Teeth replacement, tell us why.
Please Choose if you would like to know about permanent replacements?
Please Choose if you ever had any problems or complications with previous dental treatment.
If You had problems or complications please, explain
Please choose if you feel your breath is offensive at times?
Please choose if you had any orthodontic work?
Please choose if you clench or grind your teeth?
Please choose if your jaw clicks or pops?
Please choose if you experienced any pain or soreness in the muscles or your face or around your ear?
Please choose if you have frequent headaches, neckaches or shoulder aches?
Please choose if food gets caught in your teeth?
Please tells us are any of your teeth sensitive to:
Please choose if you experience dry mouth?
Please tells us How often do you brush your teeth?
Please choose if your gums bleed or hurt?
Please tell us when you brush your teeth.
Please choose if you use Dental Floss
Please tell us how often you use floss.
Please choose if any of your teeth are loose, tipped, shifted or chipped?
Please choose if you are unhappy with the appearance of your teeth?
Please choose if you ever had gum treatment or surgery?

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Please let us know the details of what type of gum treatment or surgery you had, where you had it, and when you had it.

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Please let us know if you had any unpleasant dental experiences or is there anything about dentistry that you strongly dislike?
Please choose if you have any questions or concerns?

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