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Dental History
Dental History
Dentist
Date of last cleaning
How often do you brush?
How often do you floss?
Please check if you have or have had any of the following:
Bleeding Gums
Broken/Chipped Tooth
Cleft Palate
Grinding/Clenching
Headaches (severe/frequent)
Injury to Mouth/Teeth/Chin
Jaw Pain, Click, or Popping
Lip or Cheek Biting
Missing or Extra Permanent Teeth
Mouth Breather
Nail Biting
Periodontal Treatment
Root Canal(s)
Snoring
Thumb/Finger Sucking
Tongue Thrust
Ever been evaluated or had orthodontic treatment before? If yes, explain
Attitude toward treatment and potentially braces?
May we request medical/dental and/or orthodontic records?
Yes
No
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