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8. |
Please describe any other serious illness not listed above. |
Yes No |
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9. |
(Women) Are you now PREGNANT? |
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10. |
(Women) Are you NURSING? |
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11. |
Has your dental care been IRREGULAR in the last 5 years? |
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12. |
Approximate date of last dental VISIT. |
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13. |
Is your present dental health POOR? |
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14. |
Are you dissatisfied with any PAST dental treatment? |
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15. |
Have you had a BAD dental experience in the past? |
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16. |
Are you APPREHENSIVE about dental treatment? |
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17. |
Are you unhappy with the APPEARANCE of your teeth? |
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18. |
Have you worn BRACES (orthodontics) on your teeth? |
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19. |
Have you had any PERIODONTAL (gum) treatment? |
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20. |
Has it ever been RECOMMENDED to you? |
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21. |
Do your gums BLEED, feel TENDER, or IRRITATED? |
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22. |
Are you troubled by BAD BREATH? |
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23. |
What, if any, PROBLEMS are you having now? |
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24. |
Have your teeth been sensitive to: |
|
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HOT? |
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COLD? |
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SWEETS? |
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PRESSURE? |
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25. |
Does food WEDGE between certain teeth? |
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26. |
Do you have any problems with teeth/fillings BREAKING? |
| 27.
| Does your jaw POP or CLICK?
|
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28. |
Are you aware of GRINDING or CLENCHING your teeth? |
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29. |
Are your jaws or teeth SORE when you wake? |
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30. |
Do you have HEADACHES, EARACHES, NECK PAIN, or FACE PAIN? |
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31. |
Has anyone told you or do you suspect that you SNORE? |