Please check either Yes or No as applicable:
Do you have or have ever had any of the following?
- Do you have allergies to any of the medications listed below? (Please check)
- Have you noticed any of the following?
|Discomfort in face, head, neck, jaw|
|Food caught between teeth|
|Sensitivity to sweets, hot or cold|
|Teeth tender when chewing|
|Jaw clicking or popping|
|Swelling lumps in mouth|
|Bleeding or sore gums|
|Recurring sore in or around the mouth|
- Have you ever been treated by a periodontist, orthodontist or endodontist?
- If yes explain:
- Are you happy with the appearance of your teeth?
- THE INFORMATION ABOVE IS CORRECT TO THE BEST OF MY KNOWLEDGE.