Dentist Raytown, MO | Personal Care Dental Group | Dr ...



right-619125Smile Evaluation00Smile Evaluation276225-704850Personal Care Dental Group9500 E 63rd Street, Suite 103Raytown, MO 64083816-737-111000Personal Care Dental Group9500 E 63rd Street, Suite 103Raytown, MO 64083816-737-1110133350-76200000Please take a few minutes to answer the following questions. Thank you.Please check any of the following problems that may apply to you: Sensitivity (hot or cold)HeadachesTeeth of fillings breakingGrinding or clenching teethBleeding, swollen, or irritated gumsLoose, tipped, or shifting teethBad breathSnoringDo you have or have you had any of the following? DenturesPartial denturesPeriodontal (gum) treatments If so, when _______________________________Please share the approximate dates of:Your last cleaning: _______________________________Your last oral cancer screening: __________________Your last complete x-rays: ________________________Who was your previous dentist? Name: __________________________________________City: __________________________State: ____________Phone Number: _________________________________Do you like your smile? YesNoDo your gums ever bleed? YesNoHow many times a week do you use floss? _________________________________________________How many times a day do you brush? _________________________________________________Types of toothbrush bristles HardMediumSoft Do you smoke or use chewing tobacco? YesNoIf yes, how much? And, for how long? __________________________________________If you could change your smile, would you:(please check all that apply) Make your teeth whiterMake your teeth straighterReplace discolored fillingsClose spaces between your teethRepair broken, chipped, or worn teethReplace missing teethReplace old crownsHave a smile makeoverPlease rate the following on a scale of 1 to 5 (5 being the highest)How important is your dental health to you?1 2 3 4 5 How would you rate your current dental health?1 2 3 4 5 How would you rate your dental anxiety?1 2 3 4 5 Why did you leave your previous dentist? ____________________________________________________________________________________________________What is the most important thing to you about your dental visit today? ____________________________________________________________________________________________________What are your long-term dental goals? ____________________________________________________________________________________________________If there is anything you would change about your smile, what would it be? ____________________________________________________________________________________________________Please indicate any other concerns not specified: ______________________________________________________________________________________________________________________________________________________center285750Name: _____________________________________________Date of Birth: ___________/_______________/____________0Name: _____________________________________________Date of Birth: ___________/_______________/____________ ................
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