Babylon Dental Care
Identification
Male
Female
Contact
Family & Friends
Your Spouse
Person Responsible For This Account
In the event of an emergency, is there someone who lives near you that we should contact?
Your Dental History
Why have you come to the dentist today?
Do you require antibiotics before dental treatment?
Yes
No
Have you ever had a serious/difficult problem associated with any previous dental work?
Yes
No
Are you currently in pain?
Yes
No
I have a fear of/I have concerns about:
Experiencing pain
Needles
Gagging
Being embarrassed
Losing my teeth/false teeth
To understand what’s going on in my mouth, My preference is:
To know all the details
To be given the bottom line
To read pamphlets
To talk with a team member about solutions to my problems
Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)?
Yes
No
Your current dental health is:
Good
Fair
Poor
How many times a week do you floss?
Do your gums ever bleed?
Yes
No
What type of bristles do you brush with?
Hard
Medium
Soft
Are you happy with your smile?
Yes
No