ProSites, Inc.
Dental HistoryPrevious Dentists Name:______________________________________________________Last complete dental exam_____________________ Last full mouth X-rays________________What is your immediate dental concern? _________________________________________________________________________________________________________________________________________________Please Circle YES or NOAre you presently in any dental pain? YES NOHave you lost any teeth? YES NODo your gums bleed when brushing your teeth? YES NOIs any part of your mouth sensitive to pressure, temperature, food or drink? YES NODoes food catch between your teeth? YES NODo you have pain or soreness around your eyes, ears, or other parts of your face? YES NOAre you aware of stiff neck muscles? YES NODo you ever awaken with an awareness of your teeth or jaws? YES NOAre you aware of clenching or grinding your teeth during daytime hours or when sleeping? YES NOAre you aware of your jaw clicking or popping? YES NODo you have difficulty opening your mouth widely? YES NODo you have tension headaches? YES NODo you have an unpleasant taste or odor in your mouth? YES NOAre you presently satisfied with the health, comfort and function of your mouth? YES NOAre you presently satisfied with the appearance of your teeth? YES NODo you want us to inform you of the latest cosmetic options? YES NOIN CASE OF EMERGENCY PLEASE CONTACT___________________________________________Patient’s Signature _________________________________________________ ................
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