Dental Information Name First Last Date MM DD YYYY The following information is for our records and will be kept confidential.Are you having any dental pain now?* Yes No When was your last dental visit?* MM DD YYYY What was done at that time?*Do you floss?* Yes No How often?*How times a day do you brush?*What type of toothbrush are you currently using? Manual Mechanical Are your teeth sensitive to:Hot or Cold* Yes No Sweets* Yes No Biting or Chewing* Yes No Toothpaste/Rinse* Yes No Have you noticed any bad breath or bad tastes?* Yes No Do you frequently get cold sores or any other oral lesions?* Yes No Do your gums ever bleed or hurt?* Yes No Have your parents lost any teeth or had gum disease?* Yes No Do you have any family history of Diabetes?* Yes No Do you smoke, or chew tobacco?* Yes No Have you noticed any loose teeth, or a change in your bite?* Yes No Does food tend to get caught between your teeth?* Yes No Do you clench or grind your teeth while awake, or asleep?* Yes No Do you breathe by your mouth while awake, or asleep?* Yes No Do you have tired jaws, especially in the morning?* Yes No Have you had orthodontic treatment (Braces)?* Yes No Have you had oral surgery (Extractions)?* Yes No Have you had periodontal treatment (Gum Disease)?* Yes No Do you have a bite plate, or mouth guard?* Yes No Have you had a serious injury to your mouth, or head?* Yes No Clicking or popping in your jaws?* Yes No Headaches, neck or shoulder pain?* Yes No Is there anything about your smile or bite that you would wish to change?*What are your concerns (if any) about having dental treatment?* Reach Us 3475 Plymouth Blvd. Suite 200 Plymouth, MN 55447 Phone: 763-694-6158 / Fax: 763-577-1375 info@epicperio.com Map / Directions Forms New Patient Letter Patient Registration Medical History Dental History Consent Form Navigation Home Dr. Barss Dr. Jensen Services & Info Dental Professionals