Do you floss regularly? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Do your gums bleed while brushing or flossing? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Are your teeth sensitive to hot, cold or sweets? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Do you chew/smoke tobacco in any form? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you had any head, neck or jaw injuries? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Do you notice popping, clicking or soreness of your jaw? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Do you clench or grind your teeth? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you ever had orthodontic treatment? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Do you wear dentures or partials? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you ever been told you have gum disease? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Any other dental issues? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
MEDICAL INFORMATION
ALLERGIES
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Other Allergies {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
CONDITIONS
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Have you had any serious illnesses, operations, been hospitalized in the last 5 years or any other medical issues or concerns not listed above? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
{ binding firstError.message }
WOMEN
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
PATIENT'S PHYSICIAN
Name of Family Physician {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }