Name Nickname Age Referred by How would you rate the condition of your mouth? Excellent Good Fair Poor Previous Dentist How long have you been a patient? Months/Years Date of most recent dental exam Date Date of most recent x-rays Date Date of most recent treatment (other than a cleaning) Date I routinely see my dentist every: 3 mo. 4 mo. 6 mo. 12 mo. Not routinely WHAT IS YOUR IMMEDIATE CONCERN? Type a label