1. When was your last cleaning and check-up appointment?

2. Are any of our teeth sensitive to Cold Sweet Heat Other

3. Do your gums bleed when Brushing Flossing Spontaneously

4.Do you suffer from pain and /or swelling of your gums? Yes No

5.Are you aware of any loose teeth? Yes No

6.Do you chew on only one side of your mouth? Yes No

7.Habits Bite your lips or cheeks regularly? Grind or clench your teeth during the day or night? Hold any foreign objects with your teetn? eg. pencils Mouth breathe while awake or asleep?" "Bite your nails?

8.Does any part of your mouth hurt when clenched? Yes No

9.Does your jaw crack or pop when opened widely? Yes No

10.Do you have any difficulty in opening or closing your jaw? Yes No

11.Have you had any of the following: Oral Surgery Gum Surgery Braces Other appliances

12.Have you experienced any growth or sore spots in your mouth Yes No

13.Are you concerned about the appearance of your teeth and if so, what would you like to see changed? specify:

14.Would you rate your current dental health as: Excellent Good Fair Poor

15.Is your sugar intake: High Medium Low

16.Brushing: Vigorous Light How Often

17.Cleaning aids presently used: Floss Stimudents Toothpick Other

18. Do you have any emotional concerns regarding you dental visit Fear Time Money Embarrassment Pain

19. Do you have any other concerns?