Dental History 1 * Medical History 2 * 

YNPatient Signature:____________________________________________________________ Date: 11/20/2024Bad mouth odorHad periodontal/gum treatments/SRPTooth sensitivity to temperature/pressureTooth positionWhat is the reason for your visit today?Tooth shapeIf you are NOT happy with your smile, why? Check all that apply.Other reason, list below:Are you happy with your smile?Tooth ColorBleeding gumsHad problems with previous dental txDifficulty opening mouthClench/grind teethFood trapped in spacesWear dentures/partialsHad sores/ulcers in mouthCurrent dental pain/discomfortDental tx makes you nervousWear retainersWear nightguardDate of your last cleaning at the dentist?Have dry mouthCheck all that apply:Drink bottled/filtered waterOrthodontic tx/bracesHave/had loose teethPainful chew/bite/swallowMissing teethSerious injury to head or mouthHad earaches/neck painDental HistoryJaw click, pop or painBroken fillingsBy checking this box, I acknolwedge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly.Date: 11/20/2024First Name:Last Name:Birthdate:I am aware that I must notify the practice of any future changes.This will serve as my electronic signature.There are no other medical conditions or medications/allergies that have not been listed