Bella Vista Dentistry (719) 593-9182



DENTAL HISTORY

Date of last dental examination and cleaning Where X-rays

**Check mark all appropriate responses**

1. ( Do your gums bleed while brushing or flossing

2. ( Are your teeth sensitive to hot or cold liquids or foods

3. ( Are your teeth sensitive to sweets and /or sour liquids or foods

4. ( Do you have any sores or lumps near your mouth. Where

5. ( Have you had any head, neck or jaw injuries? Year Treated

6. ( Have you ever experienced any of the following problems in your jaw?

( Clicking

( Pain (joint, ear, side of face)

( Difficulty with opening or closing?

( Difficulty in chewing

7. ( Do you have frequent tension headaches. How often

8. ( Do you clench or grind your teeth

9. ( Do you bite your lips or cheeks frequently.

10. ( Have you ever had any difficult extractions in the past

11. ( Have you any orthodontic work? when completed? # of years

12. ( Have you ever had any prolonged bleeding following extractions?

13. ( Have you ever had instruction on the correct method of brushing your teeth?

14. ( Have you ever had instruction on the care of your gums?

15. What type of filling do you prefer? ( Silver ( Tooth Colored ( Doesn't Matter

AUTHORIZATION AND RELEASE

I certify that I have read, understand and have accurately answered the medical and dental questions to the best of my knowledge. I understand that providing incorrect information can be dangerous to my health. I authorize Dr. Levasseur to release any information including the diagnosis and the records of any treatment or examination rendered to my child or me during the period of such dental care to third party payers and or health practitioners.

Signature of patient or parent (if minor) Date

Please check any of the following dental topics or treatments that you might be interested in or would like to have more information about:

( Tooth Whitening/Bleaching ( Implants ( Crowns

( Dentures ( Partials ( Tooth Colored Fillings

( Closing Spaces or Gaps ( Tooth Wear ( Sealants

( Fluorides ( Esthetics ( Bad Breath

( Gum Disease ( Root Canals ( Straightening

( OTHER

Sterilization Procedure of the Dental Office: Our office complies with the standards set by OSHA. Please ask if you would like to know more on how we sterilize and disinfect between patients or if you have any questions regarding these procedures.

Thank you for your cooperation in helping our office make your dental experience as pleasant as possible. Please do not hesitate to ask on of our staff members tf you have other concerns or questions.

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