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What Type of services do You need from a Dentist?
     
 
Date of most recent dental examination:
How often do you brush your teeth?
How often do you floss?
     
     
YES NO DENTAL HISTORY
     
Teeth sensitive to hot or cold; teeth throb or ache?
Started teething very early or late?
Bleeding gums, bad breath, mouth odor?
Periodontal "Gum Problems"?
"Gum Boils", frequent canker sores, cold sores?
Are you taking any forms of fluoride?
Thumb, finger, sucking habit?
Abnormal swallowing habit (tongue thrusting)?
History of speech problems?
Any pain in jaw or ringing in the ears?
Do you experience any pain or soreness in the muscles of the face, or around the ears?
Difficulty encountered in chewing or jaw opening?
Any teeth irritating cheek, lip, tongue, palate?
Any wisdom tooth problems?
Have you ever had a prior orthodontic examination or treatment?
Have You ever had periodontal (gum) treatment?
Would  You object to wearing orthodontic appliances (braces) should they be indicated?
     
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