Dental History Form Page 2

19. How often do you brush your teeth? __________________________

20. How often do you floss? ___________________________________

21. Are you happy with your smile?

YES NO

22. Do you feel your breath is offensive at times?

YES NO

23. Have you ever had gum treatment or surgery?

YES NO

24. Are you aware of tonsil stones?

YES NO

25. Do you any questions or concerns?

YES NO

I CERTIFY THAT THE ABOVE INFORMATION IS COMPLETE AND

ACCURATE.

PANTIENT’S/ GUARDIAN’S SIGNATURE

_____________________________________

DATE____________

642 Shadows Lane

Phone: (225) 926-1059

Baton Rouge, LA 70806

Email:

Fax: (225) 924-6570

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Parent category: Medical