Form: Denture Dental Health History

Sensitivity to

Oral Malodor (Bad Breath)

Pressure from biting or chewing

Bad Taste

Hot Cold Sweet

Dissatisfied With Appearance of My Teeth

Chipped/Broken Teeth

Teeth Clenching/Grinding

Teeth wearing away abnormally

Uncomfortable or Uneven Bite/Bite Changing

Crooked or Tipped Teeth

Jaw Joint (TMJ) Pain/Soreness/Discomfort

Loose Teeth

Jaw Joint (TMJ) Noise (Popping/Clicking)

Missing Teeth

Pain or Ringing in The Ears

Gaps/Food Traps between teeth

Difficulty Opening Mouth or Chewing

Dry Mouth or Constantly Thirsty

Bite Uneven or Changing

Burning Sensation in Mouth/Tongue

Headaches/Migraines

Smoke or Use Chewing Tobacco

Pain or Soreness Around Eyes/Ears

Growths or Swellings in Mouth

Vertigo, Dizziness or Balance Problems

Bleeding, Swollen or Irritated Gums

Facial, Head, Neck or Shoulder Pain/Stiffness

Grooves or Recession at Gumline

Allergic to Dental Materials

Your Name (required)	Your Email (required)
Specialty Dentist:	Period of Treatment:
Address:	City:
State:	Zip:
Email:	Phone:
Date of last complete x-rays? /	Date of last oral cancer screening /
Date of last cleaning? /	What is the most important thing to you about your dental visit today?

Dentures or Removable Partial Dentures
Fixed Bridge	Jaw Surgery
Braces or Clear Braces	Root Canals
Dental Implants	Sleep Apnea
Crowns	CPAP Machine or Sleep Appliance
Veneers	Night Guard
Any Serious Trouble With Past Dental Treatment	Fear or anxiety level regarding dental treatment
	012345678910

Make My Teeth Whiter
Make My Teeth Straighter	Replace Missing Teeth
Close Spaces or Gaps That Bother Me	Replace Old Crowns That Don't Fit Right or Match
Replace Dark Fillings With Tooth Colored Replacements	Have A Smile Makeover
Fix My Teeth So I'm Not Embarrassed To Smile	Stop My Jaw From Hurting or Clicking
Repair Chipped Teeth

Please check conditions that apply to you