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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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