Reason for visit:Approximate date of last dental visit: What is your primary concern that you would like us to address first? When would you like us to start treatment? Have you ever had any serious problem associated with previous dental treatment? Yes No Is so, explain: What, if anything, has happened in previous experiences at the dentist that was reason not to return? Do you have missing teeth? If yes, have you had them replaced? If you have had missing teeth replaced, are you happy with the results? If not, would you like to learn about your options to replace them? Do you ever feel (or have you ever been told) that you don't have fresh breath? How often do you brush your teeth? How often do you floss (routinely)? What type of brush do you use? SOFT MED HARD Do you avoid brushing any part of your mouth because of pain? Yes No If yes, what part? Which foods cause you twinges of pain: hot cold sweet sour none Do you lose fillings or break fillings? Yes No

We respect your right to choose the level of care that fits your needs. We've found that many adults are unaware that problems even exist. There are rarely symptoms (pain, bleeding) associated with the aging and deterioration of teeth and gums - until it is far too late. According to the ADA, more than 80% of adult Americans have some level of gum disease. With your permission we would like to explain the choices available to achieve long-term health and beauty for your existing natural teeth. Please check all that apply: