Medical History Form Poole | Holistic Dental Practice Parkstone

Occlusal Screening

Do you clench or grind your teeth during the day?

Have you been made aware of clenching or grinding your teeth during the night?

Do you have chronic headaches, or neck and shoulder pains?

Are your jaws or teeth tired when you awaken?

Do you now, or have you ever had, pain in your jaw joint or the sides of your face (in and about the ears)?

Have your jaws ever clicked or popped when you open your mouth?

Have you ever experienced difficulty moving your jaw or opening your mouth wide?

Do you chew on only one side of your mouth?

Do any of your family, including your parents, wear dentures?
Yes No
How many dentures do you wear?
How long have you worn dentures?
Why were your teeth extracted?
If you are currently having a denture problem, is it related to:
Pain Discomfort Appearance Function

Please make sure you've checked through all the sections again. When you're happy you've answered all the appropriate questions, press submit.