Healthy Mouth Baseline Assessment

2525 Old Bronte Rd. Suite# 290, Oakville, ON, L6M 4J2      905-815-8888

The Mouth is the Gateway to the Rest of Your Body!

Patient's Name:

Patient's E-mail:

Do You have any of Following?

Oral Cancer Lumps and/or Sores Infection/Abscess

Missing or Loose Teeth Crowded Teeth Large Gaps/Spaces

Bad Breath/Taste Food Traps Dry Mouth Ice Chewing

Frequent Headaches Clenching/Grinding Excessive Tooth Wear Jaw Pain/Clicking/Popping in Joint Cheek Biting Nail Biting

%

Deep Gum Pocket Depth Bleeding/Swollen/Red Gum Plaque/Tartar Receding Gum Gum Disease Smoking Blood in Sink After Brushing

Chronic Fatigue Sleep Disorder/Snoring Tongue Tie/Lip Tie

Cavities Hot/Cold Sensitive Biting/Pressure Sensitivty Cracked/Broken Teeth Old Fillings Discoloured Teeth Acid Reflux

Confirmation: Review & Submit

Questions / Comments:

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Patient/Parent/Guardian Signature:

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