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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
DENTAL HISTORY It is important to tell all dental personnel involved in your treatment about the general state of your health. This information is confidential. Name__________________________________________Date of Birth ____________________ 1. Former Dentist __________________________Phone ______________________________ 2. When did you last visit a dentist? _____________________X-rays taken? Yes ____ No _____ 3.What was done at that time?____________________ ________________________________ 4.How would you rate your smile? (Worst) 1 2 3 4 5 6 7 8 9 10 (Best) 5. Have you lost or have had any teeth removed, including wisdom teeth? Yes ______ No______ 6. Do you have any bridge work or dentures? _________________________________________ 7. Are you unhappy with the replacement? Yes ____ No ____ Why ________________________ 8. Have you ever been told you have gum disease? Yes ____ No ____ 9. Have you ever had gum treatment or Surgery? Yes ____ No ____ 10. Does food chronically collect between your teeth? Yes ____ No ____ 11 Are your teeth acutely sensitive to: Sweet o Cold o Heat o Pressure o No o 12. How often do you brush your teeth? _____________________________________________ 13. How often do you floss your teeth? ______________________________________________ 14Reason for today’s visit? ()Exam ()Emergency ()Consultation 15.Are you in pain? ()Yes ()No How long? _________ 16.Please indicate any of the following problems: ()Discomfort, clicking or popping in jaw. ()Lost / Broken Filling(s) ()Stained teeth ()Bad Breath ()Red swollen or bleeding gums. ()Locking jaw ()Ringing in ears ()Sensitive tooth, teeth or gums ()Blisters-Sores in or around the mouth ()Broken / Chipped tooth ()Teeth grinding ()Other____________________________________________ 17. Do you have frequent headaches? Yes ____ No ____ 18. Have you had any orthodontic work? Yes ____ No ____ I certify that the above information is complete and accurate. Patient's/Guardian's Signature_____________________________ Date____________________