DENT by tyndale

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									        Name:                                                Today'sDate:
        The reasonfor your visit todav is:
        The dateyou lastvisiteda dentistwas                       cleaning
                                                         Lastdental      was on
D       Howoftendo you normally  havedental checkupsand cleanings?
                                     Your previousDentist'sinformation
                                                                     :

E      Name
       Address                             City
                                                                         Phone
                                                                         State               zip
       Pleasetell us why,if you are changing
                                           dentists
N                                                                               yes          item)
                                                                            answer ornororeach
        Please circle the appropriate answer for each of the following(ptease
T                   Do You:                                              Are any of your teethsensitive
                                                                                                      to:
A        N O YES Havebadtastesor mouth
                         get
         N O YES Frequently coldsores,
                                      odorfrequently
                                     blisters, other
                                            or
                                                               NO YES Hotor Cold

L                 orallesions
                                   gums
         N O YES Havesoreor bleeding
                                                               NO YES Sweets
                                                               NO YES Biting/chewing
                                                                         Haveyou had any of the following:
         MO YES Haveanylooseteethor changes your
                                          in
                                                               N O YES OralSurgery
                  bite
                                                               NO YES PeriodontalSurgery
                          get
             YES Frequently foodcaught     your
                                     between
                                                                              injury youheador mouth
                                                               NO YES A serious    to
                  teeth Where?
H            YES Haveparents                 gum
                           who haveexperienced
                                                               NO YES Orthodontic
                                                                               treatment
                                                                              removable
                                                                                       (Braces
                                                                                             or
                                                                                      appliances)
 I                disease toothloss
                      or
                        or
         N O YES Clinch grindteethwhileawake asleep
                                            or
                                                               NO YES Yourteethground
                                                               NO YES A biteor mouth
                                                                                      downor adjusted
                                                                                    guard
S        NO YES Biteyourlipsor cheeks
         N O YES Holdobjects yourteeth(pencils,
                           with
                                    regularly
                                             pens,
                                                               Areyounervous
                                                                           abouthaving
                                                                                     dentaltreatment?
                                                                         NO            YES
T                 nails)
                            whileasleep/awake
         N O YES Mouthbreathe
                                                                                           dentalvisit
                                                               lfyou haveeverhadan upsetting

o        N O YES Usetwopillows
                             whensleeping
                  ln the last 5 monthshave
                                                               please
                                                                    describe



R                     you experienced:
         N O YES Clicking popping thejaw
                        or      of
                                                                            YESto any of the aboveplease
                                                               lf youanswered
                                                               describe

Y        N O YES Pain(oint,ear,sideof face)
                                                               Are yousatisfied theway yourteethlook?
                                                                              with
                         in               yourmouth
         N O YES Difficulty opening closing
                                  or
                                                                         NO            YES
         N O YES Difficulty
                         chewing either
                                on     sideof your
                 mouth                                         Wouldyouliketo keepyour teeth of yourlife?
                                                                                            all
         N O YES Head,               aches
                       neckor shoulder                                   NO            YES
                                 in
                         especially themorninq?
         NO YES Tirediaws,

The information bothsidesof thisformis trueto the bestof my knowledge. further
                 on                                                   lf                is
                                                                              information
needed givethisofficemy permission contact respective
       I                            to      the           healthcareproviders release
                                                                            to        such
information. hereby
            I        authorize Doctor takex-rays,
                             the       to           studymodels, photographs, anyother
                                                                            or
          aids
diagnostic deemed      appropriate the Doctor makea thorough
                                 by          to                diagnosis my dentalneeds.I
                                                                         of
alsoauthorize Doctor perform andall formsof treatment,
               the      to       any                                              that
                                                             medication therapy, maybe
                                                                       and
indicated,further
         I         authorize consent the Doctor
                           and        that         choose andemploy  suchassistancedeemed  fit.
I understand is my responsibility notify the doctor of any changesin my healthor medication
              it                  to
on an ongoingbasis.
PatientSignature                                              Date
                   lf patient a minor
                            is                 Signature
                                    ParenVGuardian

								
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