Dental Information
Dr. Daniel C. Sluyk, DDS
How would you rate the condition of your mouth?
Excellent
Good
Fair
Poor
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How often do you routinely see your dentist?
3 month
4 month
6 month
12 month
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What is your immediate concern?
Are you fearful of dental treatment? If yes, how fearful, on a scale or 1 (least) to 10 (most)
Personal history, check all that apply:
Had an unfavorable dental experience
Had any reactions to local anesthetic
Had any teeth removed
Had complications from past dental treatment
Had/have braces, orthodontic treatment
Had trouble getting numb
Had your bite adjusted
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Smile Characteristics, check all that apply:
Is there anything about the appearance of your teeth that you would like to change?
Have you felt uncomfortable or self-conscious about the appearance of your teeth?
Have you ever whitened (bleached) your teeth?
Have you been disappointed with the appearance of previous dental work?
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Bite and Jaw Joint, check all that apply:
You have problems with your jaw joint
You have any problems chewing
Your teeth changed in the last 5 years, have become shorter, thinner, or worn
You chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits
You clench your teeth in the daytime or make them sore
Your teeth are crowding or developing spaces
You have problems with sleep, or wake up with an awareness of your teeth
You wear or have worn a bite appliance
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Tooth Structure, check all that apply:
Cavities within the past 3 years
Your teeth are sensitive to hot, cold, biting, sweets, or you avoid brushing any part of your mouth
The amount of saliva in your mouth seems too little, or you have difficulty swallowing food
Your teeth have grooves, notches, chips, a cracked filling, or pain
You notice or have holes (i.e., pitting, craters) on the biting surface of your teeth
Food gets caught between your teeth
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Gum and Bone, check all that apply:
Gums bleed when brushing or flossing
Experienced gum recession
Treated for gum disease or were diagnosed with bone loss
Had any teeth become loose on their own (without injury) or have difficulty eating an apple
Noticed an unpleasant odor or taste in your mouth
Experienced a burning sensation in your mouth
History of periodontal disease in your family
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First Name
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