Adult Pre-Clinical History Page 3
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4DENTAL HISTORY
On a scale of 1 to 5 (1 low/poor, 5 high/good) please
rate
:
How do you feel your overall dental health is: ..........................................................................................
1 2
3
4 5
Over the last ten years rate how faithfully have you had your teeth cleaned:................................................1 2 3 4 5
What is your level of sensitivity to dental procedures? ..............................................................................1 2 3 4 5
How do you feel about your smile and the look of your teeth: ....................................................................1 2 3 4 5
Date of your last hygiene visit? _____/_____/_______
Are you interested in having regular hygiene cleanings?
yes
no
What is the main reason for your visit today?
Tooth pain
I need a check-up
Cleaning
Orthodontics (braces)
Whitening
Cosmetic dentistry
Sedation dentistry
Other __________________________________
Have you ever been treated for TMJ?
yes
no
Have you ever or do you suffer from headaches?
yes
no
Tension headaches?
yes
no
Migraine headaches?
yes
no
Muscle tenderness in jaw/teeth?
yes
no
I would like to learn more about:
Orthodontics
Whitening
Cosmetic dentistry
Sedation dentistry
Implants
Bridges
Veneers
Dentures
Other _____________________________________________________________________
I ____________________________________________, agree to be responsible for all charges
for dental services and materials not paid by my dental benefit plan, unless the treating
dentist has a contractual agreement with my plan prohibiting all or a portion of such charges,
to the extent permitted under applicable law. I authorize release of information relating
to this claim. I also authorize payment of dental benefits, otherwise payable to me,
to be paid directly to Stephen P. Boger Dental, DDS, PA. Initials:_________
APPOINTMENT CANCELLATION POLICY
When you schedule an appointment, we reserve that time and prepare in anticipation of
serving you. If you should need to reschedule, we kindly request that you contact us by
phone with advanced notice of two business days. We understand that conflicts arise;
however failing your appointment or canceling without adequate notice more than once
will result in a $50 charge and then discontinuation of services. Initials:_________
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