DENTAL HISTORY
Applicant's Name
*
First Name
Middle Name
Last Name
Date
*
-
Month
-
Day
Year
1. Dental complaint at the moment:
*
2. Has your dental care been?
*
Regular (recalled regularly by your dentist)
Irregular (when you felt it is necessary to seek dental care)
Infrequent (dental care when you were in pain)
3. Approximate date when your teeth were last cleaned:
/
Month
/
Day
Year
4. Were you ever treated for a painful mouth infection?
*
Yes
No
5. Have you ever had Trench Mouth?
*
Yes
No
6. Are any of your teeth loose?
*
Yes
No
7. Have you ever been treated for periodontal disease?
*
Yes
No
If so, by whom and when?
8. Have you ever had your teeth straightened?
*
Yes
No
9. Do your jaws ever feel tired?
*
Yes
No
10. Do you ever have pain in or near your ear?
*
Yes
No
11. Do you "grind" your teeth during the day or night?
*
Yes
No
12. Does food catch between your teeth?
*
Yes
No
If so, where?
13. Does heat, cold or sweets cause pain in your mouth?
*
Yes
No
If so, where?
14. When do you brush your teeth?
*
15. Do you use anything other than a tooth brush to care for your teeth and gums?
*
Yes
No
If so, what?
16. Do your gums bleed while you brush your teeth?
*
Yes
No
17. Do you notice a bad taste in your mouth?
*
Yes
No
18. Have you ever had a gum abscess (gum boil)?
*
Yes
No
Applicant's Signature:
*
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