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Dental History

Vitta Dental

80 Park Avenue Suite 1A,
New York, NY 10016
(518) 254-6451

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Dental History( * mandatory to fill )
  •  Bad Breath
  •  Bleeding Gums
  •  Blisters on Lips or Mouth
  •  Finger Nail Biting
  •  Grinding Teeth
  •  Lip or Cheek Biting
  •  Loose Teeth or Broken Filings
  •  Orthodontic Treatment
  •  Pain Around Ear
  •  Periodontal Treatment
  •  Sensitivity to Cold
  •  Sensitivity to Heat
  •  Sensitivity to Sweets
  •  Sensitivity When Biting
  •  Frequent Headaches
  •  Jaw,Head or Neck Injuries
  •  Jaw Difficulty: Clicking and/or Pain
  •  Tooth Pain
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