21. Are you pregnant?

22. Do you have any problems associated with your menstrual period?

23. Are you nursing?

24. Have you had any serious trouble associated with any previous dental treatment?

If so, explain

25. How often do you brush your teeth?

26. Do you use dental floss?

27. Do your gums bleed or hurt?

How often?

28. Are any of your teeth sensitive to:

29. Does food get caught in your teeth?

30. Do you have frequent

31. Do you clench or grind your teeth?

32. Have you experienced any pain or soreness in the muscles of your face or around your ear?

33. Does your jaw click or pop?

I hereby certify that I have read the foregoing and have filled out this health questionnaire completely. I have advised you of all medical problems of which I am aware. I further certify that I, the undersigned, consent to the performing of x-rays and examination.
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SIGNATURE OF PATIENT OR GUARDIAN if patient is a minor X

DATE