Are you having any pain or discomfort at this time?
Have you ever had a full mouth x-rays taken of your teeth? if yes, when?
Have you ever had treatments for your gums?
Do your gums hurt or bleed when you brush?
Do your teeth hurt when you chew?
Have you ever had orthodontic treatment or worn braces?
Have you ever been aware of a bad odor or taste in your mouth?
Are your teeth sensitive to hot, cold or sweet?
Do you clench or grind your teeth during day or night?
Do you ever wake up from sleep due to shortness of breath?
Are you on a special diet?
Do you use a tobacco products?
Do you use alcoholic beverages?
Have you been a patient in the hospital during past two years?