420 N Evergreen Rd # 400, Spokane Valley, WA 99216

Patient Forms
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Please fill out all the information to the best of your knowledge. All answers will be kept confidential. If you have any questions, please ask us, and we'll be happy to assist you.
Birth Date:
   









What other dental aids do you use?
Electric ToothBrush Manual Toothbrush Soft Medium
Hard Toothpick Flouride Rinse Other
 
Have you received any formal oral hygiene instrucions? Yes No

Do you like your smile? Yes No



Are you interested in straightening your teeth (orthodontic treatment)? Yes No
Have you had braces before? Yes No
   

Please circle YES or NO to indicate if you have had or currently have any of the following:

 
Gag easily
Yes No

Avoid brushing because of pain
Yes No

Notice slow-healing sores in mouth
Yes No

Your jaw makes noise OR gets stuck
Yes No

Earaches or pain in front of your ears
Yes No

Habitually chew gum
Yes No

Gums bleed easily
Yes No

Discomfort with HOT foods/liquids
Yes No

Clench or grind your teeth frequently
Yes No

Temporamandibular jaw disorder
Yes No

Take fluoride supplements
Yes No

Difficulty chewing
Yes No

Gums bleed when flossing
Yes No

Discomfort with COLD food or liquids
Yes No

Pain in face, cheeks, jaw joints
Yes No

Chew on only one side of your mouth
Yes No

Gums feel swollen or tender
Yes No

Discomfort with SWEET or SOUR foods
Yes No

Discomfort when chewing
Yes No

Have trauma to the jaw
Yes No

If you could change your smile, what would you like to change? (please check)

The color of my teeth
The shape of my teeth
The position or alignment of my teeth
Close spaces or restore worn and broken teeth

I'm interested in (please check)

Teeth Whitening
Straight Teeth
Replacement of missing teeth
White fillings
Breath control
 
A serious injury to the mouth or head
Yes No

Food collection between teeth
Yes No

Oral Surgery (Extractions)
Yes No

Endodontic Treatment (Root Canals)
Yes No

Periodontal Treatment (Gums- Deep Cleaning)
Yes No

If yes, Please indicate:
Osseous Surgery
Tissue Gingival Grafts
Tissue Management (Scaling, Curetage)
Do you feel nervous about having dental treatment?
Yes No

Have you ever had an upsetting dental experience?
Yes No

Do you have any other concerns about your mouth?
Yes No

 
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
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