Dental History Form

Have you ever had?

Orthodontic TreatmentOral SurgeryPeriodontal TreatmentYour Bite AdjustedWorn a bite plate/night guard

Have you noticed?

Loosening of your teethFood catching between your teethPain/Swelling of gumsSores or growths in your mouthBleeding gums when brushing & flossingBad breathDo you smoke or chew tobacco?

Have you heard of Periodontal Disease?

YesNo

Do you want to keep your remaining teeth?

YesNo

Have you experienced?

Clicking of the jaw?Pain (joint, ears, side of face)Difficulty in opening/closing your mouthDifficulty in chewing, favor one sideBleeding gums when brushing & flossing

Are you pleased with the quality of your smile? *

YesNo

If you could change your smile, what would do? (check all that apply)

Whiten TeethStraight TeethLengthen TeethShorten TeethReplace TeethFix SpacesReplace FillingsLess GummyEverything!