New Patient Step 4

Ultrasmile/New Patient Step 4

Personal history

Are you fearful of dental treatment?
YesNo

Have you had an unpleasant dental experience?
YesNo

Have you ever had complications from the past dental treatment?
YesNo

Have you ever had trouble getting numb or reactions to local anaesthetic?
YesNo

Did you ever have braces, orthodontic treatment or had your bite adjusted?
YesNo

Have you had any teeth removed?
YesNo

Is there anything about the appearance of your teeth that you would like to change?
YesNo

Have you ever whitened (bleached) your teeth?
YesNo

Are you self conscious about your teeth?
YesNo

Have you been disappointed with the appearance of previous dental work?
YesNo

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