YES NO
Has the Patient Seen a General Dentist in the Last Year
Any Pain, Clicking or Discomfort in or Near the Ears (Jaw Joints)
Has the Mouth, Face or Teeth Been Injured by a Fall or Accident
Have you Been Informed of Missing or Extra Permanent Teeth
Are You Aware of Any “Gum” Problems
Have the Patient’s Tonsils or Adenoids Been Removed
Thumb or Finger Sucking (Past Age 5)
YES NO
Speech Problem or Speech Therapy
Clenching or Grinding Teeth
Has the Patient Been Examined by an Orthodontist Before
Have Other Member of the Family had Orthodontic Treatment
Are You Happy About Your Teeth and Smile