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Confidential Questionnaire

Relationship Status

Telephone/Contact Info

Do you have any family members/friends that are patients of this office?
How did you hear about us?

Dental Insurance Primary Coverage

Dental Insurance Additional Coverage

Best Time to Contact You

Dental History

Are you experiencing any dental pain?
Have you noticed any loose teeth or shifting?
Are any of your teeth sensitive to heat, cold, sweets or pressure?
Have you ever had periodontic (gum) treatment?
Do you have pain in your jaw joints, around your ear or side of your face?
Pain when teeth are clenched?
Do you clench or grind your teeth?
Are there growths or sore spots in your mouth?
Does food get caught between your teeth?
Have you been advised to take antibiotics before a dental appointment?
Do you use dental floss, proxabrush or stimudents?
Do you feel that you have bad breath?
Any difficulty opening or closing your jaw?
Pain and/or difficulty chewing?
Are you happy with the appearance of your teeth?

Medical Information

Are you currently under the care of your physician?
Are you presently taking any drug or medication or have taken any in the last 6 months?
Have you ever been hospitalized or have you ever had surgical intervention other than dental?
Are you presently taking any homeopathic products?
Have you ever been diagnosed or treated for cancer?
Have you ever had heart problems such as angina, stroke, heart murmur or valvular problems
Do you smoke?
Is there anything concerning your health you wish to discuss privately with your dentist?o you smoke?
Are you allergic to or have you ever had reactions to:

For Women Only

Are you pregnant or think you are pregnant?
Are you presently nursing?
Are you presently taking oral contraceptives?

Health History

Have you ever been treated for:

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