New Patient Form Page 7
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16Harmony Family Dental
Harmony Family Dental
10103 N. DIVISION SUITE 201
SPOKANE, WA 99218
509-467-1562
Facial/Jaw Pain
Frequent headaches
Pain in temples
Jaw injury
Pain around ear
Avoid certain foods
Jaw locks open/closed
Head injury
Popping/clicking
Pain in jaw
Neck injury
Other Concerns
Smoking/dipping
Orthodontic treatment
Snoring
Biting cheeks or lip
Burning tongue
Teeth straightening
Popping/clicking
Tooth replacement
Retainer
TMJ
Fractured tooth syndrome
Dry mouth
Tooth-colored fillings
CPAP
Wisdom teeth extraction
Wisdom teeth
Implants - Tooth #:
Cosmetics
Nail-biting
Jaw locks open/closed
Smile makeover
Sleep apnea
Stain
Dental phobias
Limited orthodontics
Chew on one side
Does food tend to get caught between your teeth? If yes, where?
Yes
No
Do you hold foreign objects (pencils, pipe, pins, nails, fingernails, etc.) with your teeth? If yes, what?
Yes
No
Have you ever had:
Check all that apply.
Orthodontic treatment
Periodontal treatment
Your bite adjusted
Oral surgery
Your teeth ground
A bite plate or mouth guard
Any canker sores or cold sores on your lips, tongue, gums, or body
A serious injury to the mouth or head? If yes, please describe including cause:
Ratings
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On a scale of 1-5 (1 bad, 5 good), please rate how you feel your overall dental health is.
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On a scale of 1-5 (1 bad, 5 faithful), over the last ten years, rate how faithfully you have had
your teeth cleaned.
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On a scale of 1-5 (1 not sensitive, 5 very sensitive), what is your level of sensitivity to dental
procedures?
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On a scale of 1-5 (1 not sensitive, 5 very sensitive), what is your sensitivity to dental cleaning
appointments?
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On a scale of 1-5 (1 unhappy, 5 very happy), rate how you feel about the look of your smile.
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On a scale of 1-5 (1 poor, 5 great), how do you rate your quality of sleep?
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On a scale of 1-5 (1 being low, 5 being high), if you snore, how would you rate the severity of
your snoring?
Page 7/16
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