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Dental History
Full Name
*
First Name
Middle Initial
Last Name
Date of Birth
*
/
Month
/
Day
Year
Dentist's Name
*
First Name
Last Name
Dentist's Phone Number
*
Dentist's Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Date of Last Dental Exam and Cleaning:
*
/
Month
/
Day
Year
Date
How frequent are the Dental Exams?
*
Every 3 months
Every 6 months
Every 12 months
Other
Any unfinished care to be completed by Dentist? Please specify
*
Have you had Orthodontic treatment before?
*
Yes
No
At what age did you have Orthodontic treatment?
*
How long did the Orthodontic treatment take?
*
Previous Orthodontist's Name
*
First Name
Last Name
Previous Orthodontist's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Previous Orthodontist's Phone Number
*
Any facial or dental injuries? Please specify
*
Any history of finger or thumb sucking? Has it stopped?
*
Do you play a musical instrument? Please specify
*
Have any teeth been extracted? Please specify
*
Please check if you have any of the following:
*
Clenching teeth
Grinding teeth
Jaw joint clicking
Jaw joint popping
Jaw joint soreness
Ringing in the ears
Headaches (more than normal)
Mouth breathing
Muscular soreness around the head and neck
Speech problems
None of the above
Other
Signature
*
Clear
Date
*
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