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Joy C. Arend, DMD

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Adult Dental History

Step 1 of 3

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Name
MM slash DD slash YYYY
7. Have you made regular visits?
8. Were dental x-rays taken?
9. Have you lost any teeth or have any teeth been removed?
10. Have they been replaced?
11. How have they been replaced?
12. Are you unhappy with the replacement?
13. Would you like to know about permanent replacements?
14. Have you ever had any problems or complications with previous dental treatment?
15. Do you clench or grind your teeth?
16. Does your jaw click or pop?
17. Have you experienced any pain or soreness in the muscles or your face or around your ear?
18. Do you have frequent headaches, neckaches or shoulder aches?
19. Does food get caught in your teeth?
21. Do your gums bleed or hurt?
22. Do you experience dry mouth?
23. How often do you brush your teeth?
24. Do you use dental floss?
25. Are any of your teeth loose, tipped, shifted or chipped?
26. Are you unhappy with the appearance of your teeth?
28. Do you feel your breath is offensive at times?
29. Have you ever had gum treatment or surgery?
30. Have you had any orthodontic work?
32. Do you have any questions or concerns?
"I certify that the above information is complete and accurate"(Required)
By typing your full name here, you are electronically signing this document.

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Our Location

9 NE 120th Ave,
Portland, OR 97220
Phone: (503) 447-8347
Alt Phone: (503) 255-2424
Email: [email protected]

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