Dental History Adult Patient Details

Dental History Adult Dental History

DENTAL

Select Yes or No

  •  Yes
  •  No
  •  Yes
  •  No
  •  Slightly
  •  Moderately
  •  Severely
  •  Bad Breath
  •  Loosening of Teeth
  •  Receding Gums
  •  Cold Sores
  •  TMJ (Temporomandibular joint) Disorder
  •  Headaches
  •  Pain in Jaw Joints
  •  Bleeding Gums
  •  Difficulty Swallowing
  •  Sweets
  •  Temperature
  •  Night
  •  Day
  •  Night
  •  Day
  •  Pop
  •  Lock
  •  Hurt
  •  Injury
  •  Oral Surgery
  •  Orthodontics
  •  Periodontics
  •  Yes
  •  No
  •  Nitrous Oxide
  •  Drugs
  •  Or

To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health or if my medications change, I will, without fail, inform the doctor at my next appointment.

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