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PERSONAL INFORMATION
DENTAL INFORMATION & HISTORY

Have you ever had cavities?

Yes
No

Have you experienced tooth sensitivity?

Yes
No

Do you grind or clench your teeth?

Yes
No

Have you had any oral surgeries?

Yes
No

Have you ever had braces or other orthodontic treatments?

Yes
No

Have you been diagnosed with gum disease (periodontitis)?

Yes
No

Do your gums bleed when you brush or floss?

Yes
No

Have you ever been treated for gum recession or gum grafting?

Yes
No

Have you lost any teeth due to decay or injury?

Yes
No

Have you received dental implants?

Yes
No

Do you have any crowns, bridges, or dentures?

Yes
No

Do you brush your teeth at least twice a day?

Yes
No

Do you floss daily?

Yes
No

Are you taking any medications that may affect your oral health or cause dry mouth?

Yes
No

Do you consume sugary or acidic foods/beverages frequently?

Yes
No

Do you smoke or use tobacco products?

Yes
No

Do you regularly drink coffee, tea, or red wine?

Yes
No

Do you have any medical conditions that affect your dental health (e.g., diabetes)?

Do you have any allergy?

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