- Dental History -

YES  NO     Heat 

YES  NO     Cold 

YES  NO     Sweets

YES  NO     Biting Pressure

YES  NO     Does food constantly get stuck between certain teeth in your mouth

YES  NO     Do you get frustrated because you always have something to be treated or  repaired when you visit a dentist

YES  NO     Are you dissatisfied with the way your teeth look (color, shape, etc)

YES  NO     Do you have fillings that show in your front teeth that you don’t like

YES  NO     Do your gums bleed when you brush your teeth

YES  NO     Do you ever avoid any part of your mouth while brushing

YES  NO     Do you have an unpleasant taste or odor in your mouth

YES  NO     Has the fear of discomfort kept you from regular dental visits

YES  NO     Are you concerned about the finances required to return your mouth to excellent dental health

How often do you brush your teeth? ___________________________     

How often do you use floss? _________________________________  

How long since your last thorough exam with full mouth x-rays? ________________________  

If you could change the appearance of your teeth, what would you do? ______________________________

- Consent To Dental Photography -

In connection with dental services I may be receiving from Peppes Dental, I agree and consent to allow the photographs taken before, during and after completion of my dental treatments, to be used for dental records, research, education, public relations, patient counseling or other professional purposes. I further agree and consent that the photographs relating to my dental care may be published and republished either separately or in connection with each other in dental photo albums, professional journals or dental books. All photographs are the property of Peppes Dental Group, P.A.

_________________________________________________________                ________________

Signature of patient, minor’s parent or responsible party               Today’s Date