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Orthodontic Questionnaire
In order to provide you an orthodintic consultation and assess your dental concerns, please submit your information below.
Your information will be securely sent back to our team to evaluate.
Last Name
First Name
Date Of Birth
What orthodontic concerns do you have about your teeth?
Do you have any of the following problems: (Check all that apply)
Do you feel your teeth are affecting your self esteem?
Do you feel crowding/rotations are affecting your ability to effectively clean your teeth?
Do you snore?
** The doctor may have a few follow up questions for you. She may request that you fill out a Sleep Disorder Questionairre. **
Have you ever seen an Ear, Nose & Throat Specialist?
Please Explain:
Have you had orthodontics in the past?
Please Explain:
Have you ever had trauma to your face or jaws?
Please Explain:
Do you have a parent or siblings who has had orthodontic treatment?
Please Explain:
Have you ever seen a periodontist or been diagnosed with Periodontal Disease?
Please Explain:
Which treatment are you considering? (Check all that Apply)
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