Have you received medical treatment during the past year
Taking birth control pills?
Please tick any of the following that you have had, or now have...
Are you allergic to, or have you reacted adversely to any of the following?
Where shall we send for your x-rays?
How would you describe the condition of your teeth and gums?
Do you have regular dental check-ups?
Are you happy with the appearance of your teeth?
Do you have any missing teeth?
Are you aware of clenching or grinding your teeth?
Do you usually have many cavities?
Do your gums feel tender, irritated, or swollen?
Has any dental treatment been suggested that was not done?
Does food catch between your teeth?
Do you avoid chewing or brushing in any part of your mouth?
Have you lost or broken fillings?
What concerns you most about dentistry?
Do you have any concerns about your breath?
It would be helpful if you would indicate below what things you are looking for most in choosing your dentist:
EMERGENCY CONTACT DETAİLS
Please give the name and telephone number of the closest relative or friend (not living with you) to contact in case of emergency
3- COSMETİC DENTAL HISTORY(Optional)
Hold a mirror 12-14" from your face. Smile to show your teeth. Take the time to observe your teeth carefully, then answer the following questions. If you are not happy with the appearance of your teeth, ask Dr. Levey how cosmetic dentistry can improve your smile.
1. Do you like the appearance of your teeth and your smile?
2. Are your teeth all in alignment (straight)?
3. Do you have spaces that you don't like?
4. Do you like the color of your teeth?
5. Do you like the shape of your teeth?
7. Are your teeth wearing on the biting surfaces?
8. Are there old fillings or dental work you don't like looking at?
What would you like to change the most in the appearance of your teeth?
How would you like your teeth to look?
To the best of my knowledge, all answers are correct. I will notify Dr.Levey if any changes in my health or medication should occur. I consent to necessary treatment being performed on me by Dr. Levey and his staff, and also to the use of photos for educational and commercial purposes. Also, I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include, but are not limited to bruising, hematoma; cardiac stimulation; temporary or rarely, permanent numbness; or muscle soreness. I understand that occasionally needles may break and require surgical retrieval.