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:
Date Created:

Tell us about your smile:

Do you like your smile?
Yes No

Are you apprehensive about your dental w?
Yes No

Do you wear dentures?
Yes No
Do you want to save your smile?
Yes No

Any problems with your previous dentist?
Yes No
Do you want to complete your dental treatment?
Yes No

Do you chew tobacco?
Yes No

Do you have, or have you ever had, any of the following? (check all that apply)

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

Chew on only one side of your mouth
Yes No

Discomfort when chewing or opening wide
Yes No
Food catches between your teeth
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

Gums feel swollen or tender
Yes No
Difficulty chewing
Yes No

Gums bleed when flossing
Yes No

Discomfort with COLD food or liquids
Yes No

Jaws feel tired
Yes No

Pain in face, cheeks, jaw joints
Yes No

Discomfort with SWEET or SOUR foods
Yes No

Have trauma to the jaw
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.
Date:
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