Form: Dental History Continued – Long Beach Dentist Office | Call (562) 421-3747 | Holistic Dentistry CA

Your Name (required)

Your Email (required)

Reasons for previous extractions:

Date of most recent extractions:

Complications?

Did you wear partial dentures prior to having all teeth removed?YesNo

If yes, how long?

How many?

Were your partial denture experiences positive?

Negative?

If negative, why?

1st Full Denture(s): Seating Date:

Placed same day as extractions?

Length of time 1st dentures worn?

Subsequent Dentures

Dates	Reasons for replacement

Which ones are you wearing now?

Main reason for having new dentures:
Difficulty in chewingDiscomfortEsthetics

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Mon-Tues-Wed	8:00 am – 5:00 pm
Thurs	7:00 am – 4:00 pm
Friday	Closed
Sat & Sun	Closed