Patient Name

Address city zip Telephone Email

Family Dentist
Specialty

Address city zip Telephone

Other Dentist
Specialty

Address city zip Telephone

Please fill yes or no. If yes, please fill in details.

Date of last dental visit:

Date of last complete dental exam:

What is your immediate dental concern?

Have you evr been to an orthodontist? yes no

Are you presently in any dental pain? yes no

Have you ever experienced any unfavorable reaction to dentistry? yes no
What kind?

Have you lost any teeth? yes no
From what cause?

Have you ever had orthodontic treatment? yes no
When?

Do you have growths or swelling in your month? yes no
How long have they existed?

Do you have any difficulty swallowing? yes no

Do you gums bleed when you brush your teeth? yes no

Do you avoid brushing any part of your mouth? yes no

have you ever been told that you have pyorrhea? yes no
When?

Is any part of your mouth sensitive to temperature, pressure, food or drink?
yes no