In an effort to serve you better, we ask that you complete the following medical form. We will be glad to assist you with any questions you have.
NOTE: Fields marked with an asterisk (*) are required.
Why did you leave your last dentist?
How often do you have you teeth cleaned?
What is your IMMEDIATE dental concern?
Date of your last dental visit?
Date of your last dental X-Ray?
Please select YES or NO to the following:
1. Are you satisfied with the appearance of your teeth?
If no, please specify:
2. Did you have any unfavourable dental experiences?
3. Do you have dental fears?
4. Are you nervous about your dental treatment?
5. Problems with effectiveness or bad reactions to dental anesthetic?
6. Bleeding gums?
7. Avoid brushing any part of your mouth?
8. Sensitive to temperature? (hot or cold)
9. Does food get caught between your teeth?
10. Sore teeth?
11. Burning sensation in your mouth?
12. Difficulty swallowing?
13. An unpleasant taste or odour in your mouth?
14. Dry mouth?
15. Jaw problems (temporomandibular joint or TMJ)?
16. Stiff neck muscles?
17. Tension headaches?
18. Clench or grind your teeth?
19. Lost any teeth?
Do you have or have you had any of the following procedures? Please check all that apply:
Please elaborate if you have any of the above:
Supplemental Denture History:
If you are wearing a partial or complete artificial denture, please complete the following:
Clinton Dental in Little Italy
580 College Street