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Last Dental Visit? Do you love your smile?
Who was your last dentist?
When was your last dental visit?
When was your last cleaning?
Reason for leaving last dentist?
Anything we can do differently from your last dentist, to make you happy?
How often do you brush?
How often do you floss?
What toothbrush do you use?
What toothpaste do you use?
Has a dentist or hygienist ever recommended you need a deep cleaning?
Have you ever had a deep cleaning?
Have you had a positive experience at the dentist?
Have you had a negative experience at the dentist?
Tell us about your parents and siblings oral health?
Did you know health of your body is related to to your mouth health? This includes heart disease, diabetes, stroke, premature birth and cancer. Do you have any of those conditions?
1. How would you rate your smile?
2. Do you prefer to have brighter teeth?
3. While smiling, are you happy with how much your teeth show?
4. In terms of the length of your teeth, do you feel that your teeth are?
5. Would you like to change the angle or orientation (slanted or rotated) of any of your teeth?
6. Do you have any staining or mottling you'd like to have removed?
7. How do you feel about the amount of gums that shows when you smile?
8. Do you think the gum tissue around your teeth is symmetrical?
9. Do you have any dark crown margins that are visible or inflamed gums around a crown or filling?
10. Are you concerned about wear or chipping on your front teeth?
11. Are you self-conscious about visible dark metal fillings when you smile?
12. Do you have sensitive teeth due to gum recession or discoloration of teeth at gum line visible when you smile?
13. If you could make any changes to the look of your smile, what changes would you make?
Notes, Comments, or Questions
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