Date of your last cleaning
Date of your last full series x-rays
Date of last cavity detection (bitewing) x-rays
Do your gums bleed while brushing or flossing ?
Are your teeth sensitive to hot, cold or sweets ?
Do you get frequent fever blisters, mouth ulcers, or sores on your lips or in your mouth ?
Have you ever had burning of the tongue or cracking of the corners of your mouth ?
Do you chew/smoke tobacco in any form ?
Have you had any head, neck or jaw injuries ?
Do you notice popping, clicking or soreness of the jaws or points just in front of the ears?
Do you clench or grind your teeth ?
Have you ever had orthodontic treatment ?
If Yes, date of placement
Do you wear dentures or partials ?
If Yes, date of placement of dentures ?
Are you happy with your dentures ?
Are you having any specific problems with your teeth, gums, or mouth at this time ?
Are you happy with your smile ?
Do you have problems with teeth/fillings breaking ?
Do you regularly use dental floss ?
Do you have, or have you ever been told, that you have Pyorrhea (Periodontal Disease)?
Do you have difficulty in opening your mouth widely ?
Do you have an unpleasant taste or odor in your teeth/mouth ?
Does food catch between your teeth ?
Do you want to learn to control your dental disease and retain your teeth ?
Any Disease, Condition or Problem not Listed ? Please list
