Please circle the appropriate answer for each condition/disease.

1. Have you had any serious problem(s) with any previous dental treatment?

2. Have you ever had an injury to your face, jaw, or teeth?

3. Do you ever feel like you have a dry mouth?

4. Have you ever had an unusual reaction to local anesthetic (numbing)?

5. Do you wear full or partial dentures?

6. Have you had any teeth replaced with a dental implant(s)?

7. Have you had any teeth replaced with a fixed bridge(s)?

8. Have you ever had any of the following treatment(s)?

  • Gum/periodontal treatment

  • Orthodontics (braces)

  • Endodontics (root canal)

  • Extractions (teeth removed)

  • Bleaching/whitening

9. Do you have any piercings in the head and neck area?

Have you ever had any Lip, Jaw or Gum Augmentation (fillers)?

Check if you have any problems with the following:

10. Do you smoke or use tobacco in any form?

The answers to the questions listed above are accurate. I understand this information will be used to determine the dental treatment I receive in this dental office and may be shared with other medical offices only as necessary. I will notify this dental office should any information change. I hereby authorize this dental office to perform recommended services.

Clear Signature
Clear Signature