Date of your last dental examination or treatment
............................................................. |
|
Have you had any serious problems associated with
previous dental treatment?.................. |
Yes
No |
Have there been any injuries to your face, mouth or
teeth?................................................. |
Yes
No |
Has there been any treatment for problems of your
jaw joint or for facial muscle spasms?..... |
Yes
No |
Have you ever sucked a thumb or
fingers?........................................................................ |
Yes
No |
Until what
age?.............................................................................................................. |
|
Do you have any speech
problems?................................................................................. |
Yes
No |
Are you a mouth
breather?.............................................................................................. |
Yes
No |
At what
times?............................................................................................................... |
|
Have you been informed of any missing or extra
teeth?...................................................... |
Yes
No |
Does food catch or collect between your
teeth?................................................................ |
Yes
No |
Do you clench or grind
teeth?.......................................................................................... |
Yes
No |
Is there clicking, popping or grating noise from
your jaw when chewing?.............................. |
Yes
No |
Is there numbness or tingling associated with your
mouth or face?..................................... |
Yes
No |
Have you ever had orthodontic treatment or been
treated for a bad bite?.............................. |
Yes
No |
Has an orthodontist been consulted
previously?................................................................ |
Yes
No |
Have you ever had periodontal (gum)
disease?.................................................................. |
Yes
No |
Has either parent had orthodontic
treatment?.................................................................... |
Yes
No |
Has either parent had periodontal
disease?....................................................................... |
Yes
No |
Do you use a mouthguard or plastic
splint?...................................................................... |
Yes
No |