Dental and Health Questionnaire
Is there any special problem with your teeth that brought you in today?
Are you having any discomfort at this time?
Are you sensitive to:
Do you use a fluoridated toothpaste?
When do you brush your teeth?
When do you floss your teeth?
What type of water do you drink?
Do you drink soda, juice, sports or energy drinks most days of the week?
Grinding Teeth at Night
Do you smoke?
Former tobacco user?
Are you pregnant?
Do you take any over the counter medicines, prescription medicines, vitamins, supplements, or home remedies?
Congenital heart valve defect
Previous bacterial endocarditis
Heart valve replacement / pacemaker
High blood pressure
Diabetes in your family
Fainting / Dizziness
AIDS / HIV SIDA / HIV
Epilepsy / convulsions
Please use your mouse or touchpad to sign your name in the grey section below, then click “Submit Form” to submit your request.