This document contains a dental health history questionnaire asking the patient questions about any dental work they have had, current pain or issues in or around their mouth, medical history including allergies or treatments, and jaw problems. It explains that once completed, the information will be reviewed and the patient contacted if any additional details are required.

1. Before we can review your photo assessment, please answer the following dental, health and history
questions:
Yes or
No
If yes, please
provide details
I have a bonded retainer:
I have bridgework:
I have crowns:
I have an impacted tooth:
I have an implant:
I have primary (baby) teeth:
I have veneers:
Do you feel pain in any of your teeth?:
Do you have any sores or lumps in or near your mouth?:
Do you currently have any head, neck, or jaw injuries?:
Do you currently experience: jaw clicking, pain, difficulty opening and/or
closing or difficulty chewing?:
Have you noticed any loosening of your teeth or do you have untreated
periodontal disease?:
Do you have any known allergies to any dental materials?:
I have a history of IV bisphosphonate treatment.:
I am currently on acute corticosteroids or in immunosuppression,
chemotherapy, or radiation of head/neck.:
I have had a bone marrow transplant or treatment of hematological
malignancies (blood cancers) within the past 2 years.:
Once we have received this information, we will review it and get back to you in case we need
further details.