Checkmark if you have ever had any of the following: |
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Checkmark if you currently have any of the following: |
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Other: |
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Give details and location of the above checked items: |
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How often do you brush? |
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How often do you floss? |
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What type toothbrush do you use? |
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Reason for today's visit |
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Former Dentist |
, Sterling-Heights/State:
Phone:
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Date and reason of last dental visit: |
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Date of last dental X-rays: |
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What have you liked about any dental office you've been to? |
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What have you liked LEAST about any dental office you've been to? |
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