4214 66 St NW, Edmonton, AB T6K 4A2 587-404-7677 780-463-8803 info@edmontonsmiles.net

INFORMATION AND HEALTH QUESTIONNAIRE

Please fill out our form below or click on the button to the right to download

To help ensure your well being while undergoing treatment in our office please answer the following questions in detail. Information will be considered confidential and for our records only.

DENTAL HISTORY

1. When was your last dental visit?
What was the purpose of it?
Have you been visiting a dentist regularly
YesNo
2. Who was your last dentist and where did he/she practice (city).
3. Why did you leave your last dentist?
4. Have you ever had any teeth extracted or pulled?
YesNo
5. Do any of your teeth ache?
YesNo
Do your gums feel tender or swollen in any areas?
YesNo
Are any of your teeth sensitive to hot, cold or sweets?
YesNo
6. Do your gums bleed when you brush?
YesNo
7.Have you ever had a bad dental experience?
YesNo
8. Do you ever experience clicking, popping, locking or soreness in your jaw joints?
YesNo
Do you ever grind or clench your teeth?
YesNo
9. What is your present dental concern?
10. On a scale of 1 to 10, how valuable are your teeth to you?


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