Are you unhappy with the appearance of your teeth?*

Do your gums bleed easily when you brush or floss?*

Do you feel your breath is offensive at times?*

Have you experienced any pain or soreness in the muscles in your face or around your ear?*

Do you have any areas of food impaction?*

Do you clench or grind your teeth?*

Do you have any swellings or lumps in your mouth?*

Have you ever had an unfavorable dental experience?*

Have you ever had any complications from an extraction?*

Have you ever had gum treatments?*

Have you ever had orthodontic treatment?*

Have you lost any teeth or had any removed?*

Have you ever had prolonged bleeding from an extraction?*

Have your missing teeth been replaced?*

Are you happy with the replacement(s)?*

Do you have any questions or concerns?*