New Patient Step 6

Ultrasmile/New Patient Step 6

Tooth structure

Have you had any cavities within the past 3 years?
YesNo

Do you have a dry mouth?
YesNo

Are any teeth sensitive to hot, cold, biting or sweets?
YesNo

Have you ever had a toothache, cracked filling, broken, chipped or cracked tooth?
YesNo

Do you avoid brushing any part of your mouth?
YesNo

Do you feel or notice any holes (i.e. pitting) in your teeth
YesNo

Gum and bone

Have you ever been diagnosed or treated for periodontal (gum) disease?
YesNo

Have you ever experienced gum recession?
YesNo

Is there anyone with a history of periodontal disease in your family?
YesNo

Do your gums bleed when brushing, flossing or eating?
YesNo

Are your teeth becoming loose?
YesNo

Have you ever noticed an unpleasant taste or odour in your mouth?
YesNo

Have you experienced a burning sensation in your mouth?
YesNo

About your health



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